Dickens, Ronald Edgar n
Ill
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ronald Edgar Dickens Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/12/2022 86 Years War or Dates 1966
i_ Place of Death Hospital,Institution or
Z_City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
pManner of Death 0 Natural Cause [Accident ❑Homicide OSuicide FlUndetermined ElPending
W
0 I—ICircumstances Investigation
W Medical Certifier Name Title
13 Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 174
EiBurial Date Cemetery,Crematory or Facility Name
11/15/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or.,.�,,.
H Hold Address
to
a' Date Point of
Cl) Transportation
p by Common Shipment
Carrier Destination
ODisinterment 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
t Remains are Shipped,If Other than Above
2 Address
Ili
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/15/2022 Registrar of Vital Statistics Caroline?ii/degarde Barber(EI ctnmica/5'Signe4J
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition lI I I b I ZZ Place of Disposition -(:.AL .7
W (address)
W
CC (section) /1 ( (lot num[I eT (grave number)
0 Name of Sexton or Person in Charge of Prrpp i es
l tease print)
Ui Signature _ Title ` � rn �Uc-
DOH-1555(07/18)p 1 of 2
1E404
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# -