O,Conner,Wlliam Patrick 3SZ
NEW YORKSTATE DEPARTMENT OF HEALTH 1 Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
William Patrick O'Connor Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/13/2021 74 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Hudson Falls Village Street Address 9 Lincoln Street, Hudson Falls Village, New York 12839
W Manner of Death Natural Cause El Accident Homicide El Suicide ❑Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Umbreen Rozell MD
Address
100 Park Street,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Hudson Falls Village 5726 5
❑Burial Date Cemetery,Crematory or Facility Name
04/16/2021 Pine View Crematory
ElEntombment Address
0 Cremation Queensbury Town,New York
ElDonation
Z ri Removal Date Place Removed
0 and/or and/or Held
H Hold Address
0
a. Date Point of
U) ❑Transportation
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
2 Address
it
W
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/15/2021 Registrar of Vital Statistics Cynthia BardTin(E(.ectronicalty Signed)
(signature)
District Number 5726 Place Hudson Falls Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition Limp izi Place of Disposition u L,i'TO(--....
(ad ress)
W
CC (section) /lotnumber/ (grave number)
Name of Sexton or Person in Charge of Pre ises
Z (pl�a a print)
W Signature s' Title ("rl 41V
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) ' 014 7 2 C
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#