Bush, Timothy NEW YORK STATE DEPARTMENT OF HEALTH t rekp B r�
Vital Records Section urial - Transit Permit
Name First Middle Last Sex
Timothy Philip Bush Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 8, 2012 50 War or Dates
I Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident I I Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Aqeel A. Gillani, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register umber
City, Town or Village Glens Falls .5-‘Q J ((��
❑Burial Date Cemetery or Crematory
November 13, 2012 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
0 Transportation Shipment
by Common Destination
O Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
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
Permission is h reb granted to dispose of the human mains scribed a ove as ndi•-ted.
Date Issued Registrar of Vital Statistics fl Q�� 7 //
(signature)
District Number l 6/ Place 6/ i i4 /t" '/ fc/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11/13/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
IA
IL (section) (lot number) (grave number)
Name of Sexton or Person in Charge o Premises G r4a ( St�+att-
(please print)
ili Signature ` Title
C iNAT e.
(over)
DOH-1555 (02/2004)