Cullen Jr, Steven NEW YORK STATE DEPARTMENT OF HEALTH t ! 115811
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Steven J. Cullen Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 19, 2014 33 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death1=1 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide Undetermined ❑ Pending
`: Circumstances Investigation
Medical Certifier Name Title
Joseph C. Mihindu, M.D. Dr.
Address
52 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register umber
City, Town or Village Glens Falls 5 b0 1 Z (;,
❑Burial Date Cemetery or Crematory t
June 23, 2014 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
.; , and/or Address
Hold
� � Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
Re❑ nterment 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
s
Permission is hereby granted to dispose of the human remains described above as ' 'cated.
' Date Issued t/2 3 j t Li Registrar of Vital Statistics W „-Q w��^�
zze (signature)
District Number 5 ((3 0 Place 6 tiar..s Rx. \\,5 , w y
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/2412014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
a (section) (lot number) (grave number)
' Name of Sexton Perso 'n harge of Premises t �A%ii 4:_iiketiLd
a (please print) _
Signature Title //J�J`
(over)
DOH-1555 (02/2004)