Anderson, Danny NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section i Burial - Transit Permit
Name First, Middle Last Sex
anny Thomas Anderson Male
Date of Death 07-26-201 8 Age 70 If War or Dates ran of U.S. 1967 69 es,
Place of Death Fort58 Edward Hospital, Institution
or
City, Town or VillageStreet AddressSeminary St.
Manner of Death r71
Lti Natural Cause ii Accident 0 Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Glen Anderson
Address 1 61 CareyRd.
Queensbury, NY
Death Certificate Filed District Number Registe Number
City, Town or Village Fort Edward .f-7 6. 9
0 Burial Date -,07-301201 8 Cemetery or Crematory Pine View Crematory
0 Entombment Address
0Cremation Quaker Rd. Queensbury, NY
Date Place Removed
❑ Removal and/or Held
and/or Address
�.a
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
AN 0Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer FIT TO 79
Address 82 Broadway Fort Edward, NY 12828
Name of Funeral Firm Making Disposition or to.Whom
Remains are Shipped, If Other than Above
Address
- Permission is her by ranted to dispose of the huma -ins described above as i icated.
Date Issued 7 7 /P Registrar of Vital Statis
(signature)
District Number-'7�s4 {-a-4 OLPlace /t ,<Jt- ��
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition']0-1 Place of Disposition p rem V Grer tyr
(address)'
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises J 4rl2.Yu i 1,s
(please print)
Signature d Title Gr-e,14
(over)
DOH-1555 (02/2004)