Dickinson, Lawrence NEW YORK STATE DEPARTMENT OF HEALTH -IL
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lawrence Dickinson Male
' Date of Death Age If Veteran of U.S. Armed Forces,
s,
December 9, 2013 90 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death a Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
_• Medical Certifier Name Title
Nawed A. Siddiqui, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
� Death Certificate Filed District Number Register Number
• City, Town or Village Glens Falls 5 60 f 21
❑Burial Date Cemetery or Crematory
December 13, 2013
❑Entombment
Address
®Cremation
Date Place Removed
Removal and/or Held
and/or Address
-; • Hold
Date Point of
❑Transportation Shipment
by Common Destination
• • Carrier
4it
❑ Disinterment Date Cemetery Address
10 r Date Cemetery Address0 Reinterment
._tea
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
we
Permission is hereby granted to dispose of the human remains described above as indicated.
/i i I Registrar of Vital Statistics ,�,�,�.,.-Q
Date Issued 12 � g ��' W
(signature)
1 District Number 56 0 j Place 6 ( c J ' l c , /U v
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/13/2013 Place of Disposition F,�,LL C�(-of;o-..
(address)
afg
.,
a (section) d, (lot number (grave number)
Name of Sexton or Person i harge of P mises r- .w�ti please print)
a a C'' Vh�
9 Signature Title
ik
(over)
DOH-1555 (02/2004)