Caro, Manuel . a-
NEW YORK STATE DEPARTMENT OF HEALTH 3Ltyy
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Manuel Caro Male
iiiiiiiii Date of Death Age If Veteran of U.S. Armed Forces,
7_7_20_11 1 88 War or Dates No
Place of Death Hospital, Institution or
City of Glens Falls Glens Falls Hospital
City, Town or Village Street Address
Manner of Death Di-Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
0 Nawed Siddi MD
iiiii
11; Address
102 Park St. Glens Falls, New York 12801
Death Certificate Filed District Number R;e� Number
'`<3 City, Town or Village City of Glens FAlls 5601
Date7-7-201 1 Cemetery or Crematory
❑ Burial Pine View Crematory
Address
ECremation 21 Quaker Road South Glens Falls, New Yokr 12804
Date Place Removed
0 ❑Removal and/or Held
•- and/or Address
Hold
O Date Point of
N❑Transportation Shipment
a by Common Destination
Carrier
El Disinterment Datb Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
;;;.:LNameofFunera1Home M. B. Kilmer Funeral Home
01 078
Riiiii Address
1376 Main St. South Glens Falls, New York 12803
iIii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
AI 11.
41.
iiiiii Permission is hereby granted to dispose of the humaQremain escrib d- abovve� as i dic= ed.
1; Date Issued 7-7-2 01 1 Registrar of Vital Statistics ii'/ e ,--C
i ature)
:::»':� District Number
5601 Place City of Gle Falls, New York 12801
im
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1 Vit Place of Disposition P,r,Va C etirt.—
+„ (address)
Ltd
>i (section) (lot numb (grave number)
GName of Sexton or Person in Charge of remises 4,,,y't't,p�c,_ „. ,_
(please print)
SignatureA �, Title 46111410(7-
(over)
DOH-1555 (9/98)