Whible Jr, Augustus NEW YORK STATE DEPARTMENT OF HEALTH : . .
Vital Records Section Burial - Transit Permit
Name First - Middle Last Sex
gii Augustus Whible Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 1 6, 2011 79 War or Dates NO
inii Place:of Death City of Glens Falls Hospital, Institution or Glens Falls Hospital
City, Town or Village Street Address
Manner of Death Natural Cause 0 Accident []Homicide El Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
CI Joseph C. Mihindu MD
Address
`": 20 Murray St. Glens Falls, New York 12801
ii<l' Death Certificate Filed District Number Regi r Number
` ] City, Town or Village City of Glens Falls 5601 1-1
Date Cemetery or Crematory
❑Burial July 19, 2011 Pine View Crematory
Address
0 Cremation 21 Quaker Road Queensbury, New York 12804
Date Place Removed
Z ElRemoval ' and/or Held
••- and/or Address
rg Hold
Date Point of
N0 Transportation Shipment
5 by Common Destination
Carrier
Disinterment Datb Cemetery Address
Reinterment Date Cemetery Address
1.1H LiPermit Issued to Registration Number
Name of Funeral Home M. H. Kilmer Funeral Home 01 078
Address
iiliii:. Main St. South Glens Falls, New York 1 288 3
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
iiiia Permission is hereby granted to dispose of the hum remains scribed above as i di -ted
iilil Date Issued 7-1 9-1 1 Registrar of Vital Statistics 277.. 4z1"e._ -
(s gn ure)
5601 Place City of GLens Falls, New York
`:I`: District Number
iiiiiiii
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
E Date of Disposition 1- Zu-i t Place of Disposition P,nti;,,v4 Cwtt of 4_
2 (address)
IL
CC (section) lot numb- (grave number)
Name of Sexton or Pe son in Charge Premises (1\r,�� 14*t
A (please print)
- I . Title Cij.LEr1 -Tom
: Signature (a 1�.
(over)
DOH-1555 (9/98)