Cisco Jr. Anthony NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anthony Cisco Jr. Male
g. Date of Death Age If Veteran of U.S. Armed Forces,
04/06/2011 69 years War or Dates 1960-1961
I- Place of Death Hospital, Institution or
W *,SC Town or Thompson Street Address Catskill Re ionai Medical Center, Harris, Ny
ct--Manner of Death Natural Cause El Accident El Homicide El Suicide Undetermined ❑Pending
LGl Circumstances Investigation
tu Medical Certifier Name Title
44 Thomas E. Warren Sullivan Co Coroner
Address
100 North Street, Monticello, New York 12701
Death Certificate Filed District Number Register Number
Town ori4.11a.ae. Thompson 5263 59
❑Burial Date Cemetery or Crematory
❑Entombment 04/11/9011 Pine View
Address
Ni Cremation Quaker Road, Queensburg, NY
Date Place Removed
Z❑Removal and/or Held
p and/or Address
F Hold -
0 Date. Point of
l Transportation Shipment
G' by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment -Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01098
Ei Address
82 Broadway, Fort Edward, NY 12828
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
• Address
Ili -
tL Permission is hereby granted to dispose of the human remains described above as-indicated.
Date Issued 04/08/2011 Registrar of Vital Statistics `, ideln-Q`z(
(signature
District Number 2 6 Place .
5263 Thompson
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ill Date of Disposition +-1I`II Place of Disposition -Pia tow Ce/n4 ofiv":
(address)
W
0
CC (section) I I(lot number) (grave number)
ct Name of Sexton or P rson in Charg oaf Premises L ��Sfi N'' �t� "
�f (please print)
L
Signature '
Title cr2t-do)Ica og_
(over)
DOH-1555 (02/2004)