Belton, Vernon NEW YORK STATE DEPARTMENT OF HEALTH 't 7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Vernon Belton Male
Date of Death Age If Veteran of U.S. Armed Forces,
41 December 12, 2014 65 War or Dates
• Place of Death Hospital, Institution or
= City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
. Medical Certifier Name Title
Shamid Ahmed, Dr.
r Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number( IJ�� Reg ist r_N er
City, Town or Village Glens Falls LC \ 0
F❑Burial Date Cemetery or Crematory
December 16, 2014 Pine View Crematory
❑Entombment Address
I 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
ElDisinterment Date Cemetery Address
❑ Renterment Date Cemetery Address
▪ Permit Issued to Registration Number
;it-' Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
-1 136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
.. Remains are Shipped, If Other than Above
Address
2
IA Permission is hereby granted to dispose of the human remains Registrar of Vital Statistics �desc 'b d bo a ' ated.
.
,. Date Issued �. j(o/20// Re 9
_ (signature)
District Number ��4,0/ Place Cl A;. /0(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
:,II, Date of Disposition 12/16/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) �j(lot numbe) (grave number)
Name of Sexton or Person in Char of Premises m}-�(„
� (p ase print)
▪ Signature L ipL. Title at'Mv+t
(over)
DOH-1555 (02/2004)