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Dickinson, Kevin Lee 411111111 # � In NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kevin Lee Dickinson Male Date of Death Age If Veteran of U.S.Armed Forces, 05/15/2023 57 Years War or Dates H Place of Death Hospital,Institution or In Z City,Town or Village Johnsburg Town Street Address 336 Oven Mountain Road,Johnsburg Town,New York 12843 p Manner of Death El Natural Cause Accident Homicide OSuicide Undetermined ❑Pending W U Circumstances Investigation Ui Medical Certifier Name Title CI Lynn Keil PA Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Johnsburg District Number Register Number City,Town or Village 5655 17 BurialH Date Cemetery,Crematory or Facility Name 05/19/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Z❑Removal Date Place Removed and/or and/or Held t— Hold Address N 0 a, Date Point of U)❑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 1— Remains are Shipped,If Other than Above " Address CC Ui a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/17/2023 Registrar of Vital Statistics jean gfComstock( ctronicalySignerl4 (signature) District Number 5655 Place Town Of Johnsburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H W Date of Disposition SI lo( ID) Place of Disposition �u `�t�,/� 2 (address) W N CC (section) d(lot number) (grave number) Name of Sexton or Person in Charge of Premises C r. .eff Z (pse print) W Signature Title DOH-1555(07/18)p 1 of 2 - Public Health Law Sec. 4145(2b) Receipt Human remains of kleilivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#