Wildermuth, Alva NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First
Middle Last Sex
Alva M. Wildermuth Female
`'A.
Date of Death Age If Veteran of U.S. Armed Forces,
git January 2, 2013 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address 62 Sisson Road
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
' ` Patricia Auer,
Address
iv. Death Certificate Filed District Number Register Number
"`°4°,' City, Town or Village
El Burial
Date Cemetery or Crematory ,l ;
: May 11, 2013 Faith Bible Baptist Cemetery P(o pc r-k..--, ,t1 G
❑Entombment Address
❑Crematisn 62 Ogden Road Queensbury,NY 12804 scoA)
Date Place Removed
❑ Removal and/or Held
_, and/or Address
Hold
. , Date Point of
�fr
.';❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
r Address
136 Main Street, South Glens Falls NY 12803
:,
5 Name of Funeral Firm Making Disposition or to Whom
.' Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r ma' s describ above as indicated.
Registrar of Vital Statisti )
;� Date Issued ���- a.(j/3 9 �ccf���� .Q./
(signature)
District Numbei1 -- — Place p z_2e,2ci jZa--Zk
: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6
Date of Disposition 05/11/2013 Place of Disposition 62 Ogden Road Queensbury,NY 12804 (J=viSr)n
(address)
5 A 1
(section) (lot number) (grave number)
v Name of Sexto e on in Charge of Premises g--e-1-,-.-s'ci L'r1 LI
. (pl ase print)
_3 Signature Title
(over)
DOH-1555 (02/2004)