Conlon, George William c.7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George William Conlon Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/06/2022 78 Years War or Dates
f• Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 238 White Birch Estates Drive,Moreau Town,New York 12828
Q Manner of Death 0 Natural Cause Accident Homicide Duicide Undetermined ❑Pending
W
0 Circumstances Investigation
WQ Medical Certifier Name Title
Paul Filion MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 25
Burial Date Cemetery,Crematory or Facility Name
05/09/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
goRemoval Date Place Removed
- and/or and/or Held
N Hold Address
0
O. Date Point of
Cl)❑Transportation
p 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
'$ Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/07/2022 Registrar of Vital Statistics Leeann Mc cabe(ECectronicaCCySigned)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W
Z Date of Disposition s Iroh2 Place of Disposition ,
(address)
W
N
(section) d(lot,number) �` (grave number)
Name of Sexton or Person in Charge of Premises t<1 L a�w1
(plead print)
W ,
Signature Title l W
DOH-1555(o7/t8)p t of 2
f3 + k%4
Public Health Law Sec. 4145(2b) ' '„ „',, ,;
Receipt
Human remains of '' delivered on , 20
Pine View Cemetery.' Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#