Carruthers, Henry NEW YORK STATE DEPARTMENT OF HEATH . "4 ' 71 Scit
Vital Records Section Burial - Transit Permit
Name First Middle Last ' Sex •
Henry D. Carruthers , Male
'! Date of Death Age if Veteran of U:S. Armed Forces,
1 2/1 /201 1 82 War or Dates 1 946-1 948
E Place of Death Hospital, Institution or
Z City, Town or Village Argyle Street Address 969 State route 197,
i Manner of Death C Natural Cause Ei Accident El Homicide 0 Suicide El Undetermined ri Pending
iti 'I Circumstances Investigation
til Medical Certifier Name Title
Thomas Kandora MD
Address
318 Broadway, Fort Edward, NY 12828
Death Certificate Filed District Number 5 .7 Register Number
City, Town or Village Argyle
Date Cemetery or Crematory
❑Burial 12.05/2011 Pine View Crematory
Address
Cremation Queensbury, NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
Date Point of
N Q Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address •
Reinterment Date Cemetery Address
Permit Issued to Registration Number
ilili Name of Funeral Home M.B. Kllmer Funeral Home 01 077
iiii Address
123 Main St. Argyle, NY 12809
.<..s Name of Funeral Firm Making Disposition or to Whom
E" Remains are Shipped, If Other than Above
im Address
rC
Permission is hereby granter: "icy di pose of th:3 human re + a aascribad ahoy indicated.
EP Date Issued 1 2/0 5/2 01 1 Registrar of Vital Statistics
igii (�7� �-�-- (signa ure)
igi
i° District Number 7S6 Place / ioUin D �f
�7
I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
W Date of Disposition Dtc.6 i toj' Place of Disposition ,a01)ku., C,c'l ctdrK*.
2 (address)
W.
cn
(section) A (Int n ber) :(grave number)
1/40 Name of Sexton or Person in Charge Premises (at (' 3en'
/� L (please print)
W TT
Signature Title C¢014100
DOH-1555 (7 0189) p. 1 of 2 VS-61