Graham, Willard 4 t ?7
NEW YORK STATE DEPARTMENT OF HEALTH w
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Willard A. Graham Male
Date of Death Age If Veteran of U.S.Armed Forces,
9/4/2016 76 War or Dates No -
Place of Death Hospital. Institution or
Cit4, Town or Village Glens Falls 1 Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑Accident EI Homicide ❑Suicide �Undetermined ❑Pending
Circumstances Investigation
Ili Medical Certifier Name Title
0 Frances C. Bollinger MD
Address
161 Carey Road, Queensbury,NY 12804
Death Certificate Filed District Numbe / , Registerplay
City,Town or Village Glens Falls `j0
Burial Date Cemetery or Crematory
09/06/2016 Pine View Crematory
['Entombment Address
[]Cremation 21 Quaker Road,Queensbury New York 12804
Date Place Removed
ri Removal and/or Held
and/or
Hold Address
; Date Point of
a 0 Transportation Shipment
a by Common ! Destination
Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
0 Reinterment t
Permit Issued to ! Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-Argyle i 01077
Address
123 Main Street,Argyle,NY 12809
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped, If Other than Above
Z Address
CC
W �.
a1 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 i 6 / /-6 Registrar of Vital Statistics t ) c.) ..Ary‘-q.. LAj-A-"'*_42________
( )
District Number 560 i Place F_. S 1�,, \\S ,A> 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (I hill, Place of Disposition er&.au✓ Gna,(err'..i
(address)
(section) riot number) (grave narthex)
Name of Sexton or Person in Charge of Premises In S���
141 ale-PA
Signature I 4 Title
(over)
DOH-1555(02/2004)