Mandwelle, Arnold • # 5-h
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit PermitVital Records Section
Name First Mid► . Last 1 Sex
Arnold Mandwelle I Male
Date of Death i Age If Veteran of U.S.Armed Forces,
7/16/2016 189 War or Dates -
Place of Death Hospital, Institution or
City, Town or Village I Street Address Deceased's Residence
Manner of Death al Natural Cause D Accident O Homicide ❑Suicide ®Undetermined ❑Pending
Circumstances Investigation
tu ical Certifier Name Title
0 Christopher Hoy
Address
161 Carey Road 12804
Death Certificate Filed District Num I Register*mbar
City,Town or Village uitAtitA si3 'tt e 51
�1
['Burial Date Cemetery or Cremory
7/21/2016 Pine View Crematory
❑Entombment Address
[]Cremation 21 Quaker Road,Qu New York 12804
Date .N. Piece Removed
Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
a by Common Destination
Carrier
; Date Cemetery Address
0 Disinterment
Date Cemetery Address
0 Remterment
Permit Issued to 1 Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home - South Glens Falls 101078
Address
136 Main Street, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
21 Address
f
Lit- -
d'' Permission is hereby granted to dispose of the human r irta de. abut rid! ed.
Date Issued <1.-1 s- I(p Registrar of Vital Statistics C.� bit A
District Number �l Place dwt_ p
I certify that the remains of the decedent identified above disposed of in accord -th this permit on:
Date of Disposition 7 i ZZIlr6 Place of Disposition 2,n‘Ott,./ ,d rnaierlr--..
(address)
(son) f ntonber)/� /'(k (grave number)
Name of Sexton or Person in Charge of Premises ,Aort _e 421 (pierase P +t) 04-
... Signature Title CT)J
(over)
DOH-f 555 (02/2004)