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Grant, Emerson r ' il6g NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Emerson C.Grant Male Date of Death Age If Veteran of U.S.Armed Forces, 11/10/2017 88 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Edit Masaba MD Address 4573 State Route 40,Argyle Town,New York 12809 Death Certificate Filed District Number Register Number City, Town or Village Argyle 5750 30 El Burial Date Cemetery or Crematory 11/14/2017 Pine View Crematory ,.r ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination ..j Carrier Li Disinterment Date Cemetery Address ❑Reinterment 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 11/13/2017 Registrar of Vital Statistics Shei(eyMc(tgrnon ECectronica1Cy Sig nee( (signature) District Number Place 5750 Argyle, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition /jl Pi(i n Place of Disposition P��.✓ /;.,r.c�c.r (address (section) (lot number) (grave number) Name of Sexton or Person in Charge of P mises f e14+16t (pl se print) Signature t Title (over) DOH-1555 (02/2004)