McGill, Jr. Roy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section f Burial - Transit Permit
Name First Middle Last Sex
Roy McGill Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
(14/05/2012 52 years War or Dates
Place of Death Hospital, Institution or
iiCity, Tow iI Street Address
y � XX Glens Falls lens Falls l-ir;spital
a Manner of Death❑N3tatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
I t Circ. 3tE ?;es Investigation
in Medical Certifier Name Title
Robert W. Sponzo M. D — -Address
102 Park Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, Towji11 'iI RXX Glens Falls 5501 154
4[['Burial Date Cemetery or Crematory
['Entombment Address
Pine View Crematorium
yi Address
❑Cjemation Queensbury. NY 12804
Date Place Removed
Z Removal and/or Held
+2❑and/or •
Address
H Hold
to
O Date Point of
ti El Transportation Shipment
a by Common Destination
Carrier
>! ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
giiii Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01078
Address
136 Main Street South Glens Falls, N Y 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tc
UI •
Permission is hereby granted to dispose of the human remains descrbed abov s i i ed.
Date Issued 04/09/2012 Registrar of Vital Statistics hi.
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k ,�
l Date of Disposition 11 (0 I(Z Place of Disposition ,✓,v4U itu C G}o f�.
',;. (address)
ILI
o
cc (section) (lot num ) (grave number)
CI Name of Sexton or Person in Charge f Premises 1k _ r r.& '+vitt-
2 (please print)
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Signature Title OM did
(over)
DOH-1555 (02/2004)