Hilder, Terry NEW YORK STATE DEPARTMENT OF HEALTH 5ry741
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Terry Lee Hilder Male
,- Date of Death Age If Veteran of U.S. Armed Forces,
July 24, 2017 69 War or Dates
kPlace of Death Hospital, Institution or
City, Town or Village Argyle Street Address 236 Plasant Valley Road
0 Manner of Death X❑ Natural Cause n Accident ❑ Homicide ❑ Suicide ❑ Undetermined 1-1❑ Pending
0 Circumstances Investigation
Lit Medical Certifier Name Title
0 John P. Stoutenberg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Argyle J -16 a \c1
❑Burial Date Cemetery or Crematory
July 28, 2017 Pine View Crematory
F❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
t❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
a. Permission is hereby granted to dispose of the human ains described above as indicated.
Date Issued -1\2 V,\\ _l Registrar of Vital Statistics 3j.j. .
„ `(1'N� ,J\1S1. '—
(signature)
District Number ;,-��SU Place GL .;--\ cA CI, ;`
I certify that the remains 77of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07�2$/2017 Place of Disposition Quaker Koad uueensbu THY e2804
(address)
IX (section) ` (lo umber) (grave number)
Name of Sexton o Perso 'n Charge of Premises �J t4, f lG.vt (4 ''fie
(please print)
Imo, Signature /'GC Title eXwrr4.10
(over)
DOH-1555 (02/2004)