Rock, Anne NEW YORK STATE DEPARTMENT OF HEALTR
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anne Marie Rock Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/05/2018 74 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death X❑Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Philip Gara MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 73
❑Burial Date Cemetery or Crematory�r
12/07/2018 ; Pine View Crematory
['Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
El❑Removal and/or Held
and/or
Address
Hold
Date Point of
<,. Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
Disinterment
. ❑Renterment
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
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/06/2018 Registrar of Vital Statistics Aimee!Mahoney(ETctronica1TySigned)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Ial7ilk Place of Disposition I t r,t v ((feN44e,
= (address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
Signature it A_ Title rema1-c--
(over)
DOH-1555 (02/2004)