Dilley, William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Sex
Name First Middle Last
William Edward Dille Male
Date of Death Age If Veterai.. firmed Forces,
May 7, 1996 90 War or Dat s wv
Place of Death Hospital, Institution or
City of Glens Falls Street Address Glens Falls Hospital
Manner of Death�Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Joseph C . Mihindukulasuri a , M . D .
Address
52 Park St . , Glens Falls , N . Y . 12801
Death Certificate Filed District Number Register Number
City, TXWOMOMW Glens Falls 5601 a1716
Date Cemetery or Crematory
❑Burial 9
®Cremation Address Queensbury, N.Y. 12804
F
Date Place Removed
Z❑Removal and/or Held
�.. and/or Address
Hold
Q Date Point of
Q Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
[ Name of Funeral Home 09168
Address
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 ir, ' aced.
Date Issued 5/8/96 Registrar of Vital Statistics ` � 1-�
(signature)
District Number 5601 Place city Clerk's Office City of Glens Falls N.Y. 12801
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
W. Date of Dispositio Place of Disposition
(address)
w
(section) (lot num r) (grave number)
F Name of Sexto or Person in Chargeof Premises C�
(please print)
SignatureAj' )'tn4LGtic.�- Title d '
DOH-1555 (10/89) p. 1 of 2 VS-61