Cicotte, Warren NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section _ Burial - Transit Permit
Name First Middle Last Sex
Warren James Cicotte Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 16, 2012 79 War or Dates Korea
Place of Death Hospital, Institution or
City, Town or Village Hebron Street Address 20 Smith Lane
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Dr. Eric Pillemer,
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number s7Y�O Register Number 471
City, Town or Village Hebron
❑Burial Date Cemetery or Crematory
April 23, 2012 Pine View Crematory
❑Entombment
Address
12 Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
s`r ❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
El Disinterment
❑ Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
Address
tm�"?
Permission is hereby granted to dispose of the human rem i s descr'bed above as indicated.
Date Issued G L Registrar of Vital Statistics 1
(signature)
District Number S�� p Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/23/2012 Place of Disposition Quaker Road Queensbury,NY 12804
-77
(address)
(section) (lot number)-. (grave number)
Name of Sexton or Per on in Charg of Premises I r twin-
"
(please print)
' Signature Title cra rtipr i0�
(over)
DOH-1555 (02/2004)