Ward Jr, Hiram NEWYORKISTATE DEPARTMENT OF HEALTH n Ig Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Hiram Sweet Ward Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 5, 2016 51 War or Dates
Place of Death Hospital, Institution or
x City, Town or Village Hartford Street Address 300 Wright Street
Manner of Death1=1 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Wesley Perry,
Address
26 Mettowee Street Granville, NY 12832
Death Certificate Filed District Number 7 - Register
City, Town or Village Hartford
3❑Burial Date Cemetery or Crematory
4 January 8, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
' Date Point of
❑Transportation Shipment
by Common Destination
may::
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h reb granted to dispose of the human remains scribed abov ID irVicated.
Date Issued ( g` Registrar of Vital Statistics dIAAA-Q ° i"
� n (signature)
District Number 5-1 S Place_ __ ' '" l
qt /Z/3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/08/2016 Place of Disposition _Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge f Premises 1as StNnt4
(p ase print)
Signature L 4 Title aftima�-
(over)
DOH-1555(02/2004)