Ross, Germanie NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
n] Name First Middle Last Sex
Germanie............................................ ...p.,..................... . ... ...... Rgss.. F
............................ .....
Date of Death Age If Veteran of U.S.Armed Forces,
1 2I 2 1 I88......................................L...........66..............!i... War orDates No .. ...
aceiiibeatii... .. Hospital, Institution or .... ....----
-til City,Town or Village Glens....Falls........ ........J Street Address 92.....flunter_St....
ili$
I öaiseofDeath
ilit3.... .. ,,.... .......PiPqP.Pt.i.Pg....1.11.b(.2 r.4.C..i.c....AP.P. r.17..Pr.rA.................................................. ........... ......--- ....------...--------------...--------
Medical*bertitier Name Title
S.R. Sp .... MD
......
Address
OL.......... 9 Q .59W.;.11......5t..,...............F.4.1.1.p..,.. .NX.„.1.. a.Q.1.................................... ....„... .. .......
]]] Deatii-baiiifiC-afe.Piied.. District Number Register Number*
City,Town or Village
Glens Fals
':.: Date :?.. Cemetery or Crematory
t Burial 12/ 27188 Pine Wiew Cemetery
0 Cremation
Address
ii
Queen.sbury, NY
. ..._........—_......._.________._._........____.____..._____._____....---.......__..__--....__.--..-----.._..____.____........
z: Date Place Removed
o 0 Removal il and/or Held
,..-,
1,...; and/or Hold ii.-.Addresi.. ....... .. .............. ..............-...................................................................................................................................................
•:-..„
Date Point ot
,f.n. EI Transportation by
Shipment
II Common Carrier : •------- --... .....
Destination
. ,
:::i:E .......-.... •
Date ::
Cemetery Address
Disinterment
Date .!
Cemetery Address . .... . ......... ..........
VI 0 Reinterment
• •• •
in Permit Issued to Registration Number
Name of.FuneralFirm.......M.M.B. Kilmer _FuneralHome01_328______„.___________
ig Address
...... 82 Broadway Fort Edward, NY 12828
Name of Funeral Firm Making Disposition or to Whom
m: Remains are Shipped, If Other than Above
... • *".
ddress
glig Permission is hereby grante to dispose of the dead,,MIn rem ns descr d above as indicated.
...--'
Date Issued „.: — ,-g_.5 --P Registrar of Vital Statistics
signature)
0 _ 2 ,
......
District Number 5.--- / Place ,-/ rie___;,;"‹. 2ef ,,e/..!--r---- , d/c....") ,/
:..:•i : I certify that the remains of the decedent identified above were dispo52f in accordance with this permit on:
'F..
Date of Disposition I?-Z 7-46" Place of Disposition
(address) )
ILI CYN.tbh •••ei IN t 5---ti i
(section) (lot number) (grave number)
Name of Sect erson in Charge of Premises .
(please'print) _---,
::11•:'4:. Signature j.... --vear .'//,1.-32.1 ,te4..... .,-k„--re i,,,k t Title 0_, ei-.
DOH-1555(9/86)p 1 of 2(formerly VS-61)