Groth, Ann ti 6°7
NEW YORK STATE DEPARTMENT OF HEALTH '. Burial " Transit PermitVital Records Section
Name First Middle Last Sex
Ann Groh Female
Date of Death i Age If Veteran of U.S.Armed Forces,
8/21/2016 179 War or Dates -
Place of Death Hospital. institution or
City, Town or Village Wilton , Street Address Home
Manner of Death in Natural Cause [0 Accident D Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation
1tf Medical Certifier Name Title
a Roslyn Socolof
Address
100 Broad Street 12801
Death Certificate Filed District Number Register Number
City. Town or Village J\pun q LP
DBuriai Date Cemetery or Crematory
8/29/2016 Pine View Crematory
❑Entombment Address
EJCremation 21 Quaker Road,Queensbury New York 12804
IDRemoval Date Place Removed
and/or and/or Held
Address
Hold
---1 Date Point of
Transportation 1 Shipment
a by Common ! Destination
Carrier
®Disinterment Date Cemetery Address
Reinterntent f Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Horne M.B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped. If Other than Above
ZE Address
CC
tF
CL' Permission is hereby ranted to dispose of the.human remains described above as Indicated.
Date Issued F a 3 / 1, Registrar of Vital Statistics (,LJ't ea-O
District Number 51,9 Place /6 i i y 6 f �, 1 1-13-77
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Date of Disposition it 1 Place of Disposition £U ./ Jr4.
(s�r�chor) (�number)(\ (grave number)
Name of Sexton or Person in 4,Charge of PAremises 12 L .;i^
in
2 s*
Signature Title / itefla
(over)
DOH-1555 (02/2004)