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Henderson, Howard NEW YORK STATE DEPARTMENT OF HEALTH / - 6 3 q 70 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Howard W. Henderson Male Date of Death Age If Veteran of U.S. Armed Forces, 4 December 2, 2016 84 War or Dates Place of Death Hospital, Institution or City, Town or Village Moreau Street Address 1467 West River Road Manner of Death .i Natural Cause 0 Accident El Homicide ❑ Suicide 0 Undetermined ❑ Pending _= Circumstances Investigation Medical Certifier Name Title Michael Adams, Dr. Address 10154 Saratoga Raod Fort Edward, NY 12828 Death Certificate Filed District Number Register Number City, Town or Village Moreau q C(p 4/ 0 v❑Burial Date Cemetery or Crematory December 5, 2016 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address a Hold Date Point of -_❑Transportation Shipment by Common Destination • Carrier ❑ Disinterment Date Cemetery Address El Reinterment Date Cemetery Address ` Permit Issued to Registration Number fl Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 4 Name of Funeral Firm Making Disposition or to Whom -: Remains are Shipped, If Other than Above 4 Address Permission is hereby granted to dispose of the human remains described above a as"ind`icated. -• Date Issued /d2/5//c Registrar of Vital Statistics �C.0�-�. (signature) District Number q 5-(o.), Place To 6.1/2 O f' �/)/Ci,GP-e - certify that the remains of the decedent identified above were disposed of in accordance with this permit on: m. Date of Disposition 12/05/2016 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of Pre ises "4if J�'^l� (please print) Signature -04_, Title «-'"'� (over) DOH-1555 (02/2004)