O'Neil, Ronald NEW YORK STATE DEPARTMENT OF HEALTH #t 5-S J
Vital Records Section Burial - Transit Permit
,, Name First Middle Last Sex
Ronald E. O'Neil Male
Date of Death Age If Veteran of U.S. Armed Forces,
o September 20, 2013 70 War or Dates
;£ Place of Death Hospital, Institution or
City, Town or Village Hudson Falls , Street Address 10 Cherry Street
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined r7 Pending
Circumstances Investigation
3= Medical Certifier Name Title
Darci Ann Gaiotti-Grubbs, M.D Dr.
Address
102 Park Street Glens Falls, NY 12801
.is Death Certificate Filed District Number Register Number
City, Town or Village Hudson Falls 5-7,cp l a.
❑Burial Date Cemetery or Crematory
September 23, 2013 Pine View Crematory
❑Entombment Address
�q ®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
%
;. 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
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued a0'l3 Registrar of Vital Statistics `5 42. " (_L. .444 (signature)
District Number S! Place f,^� �,�,Q _ 0�
1 gg
I certify that the remains of the decedent identified ab a were disposed of in accordance with this permit on:
Date of Disposition 09/23/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) in (lot number) (grave number)
4 Name of Sexton or Person i harge of Pre ises r+ster Jeh..r}}
lease print)
Signature Title MO'IZ
(over)
DOH-1555 (02/2004)