Sarchioto, Anita NEW YORK STATE DEPARTMENT OF HEALTH �13
Vital Records Section Burial - Transit Permit
77.7
44444, Name First Middle Last Sex
Anita Marie Sarchioto Female
▪ Date of Death Age If Veteran of U.S. Armed Forces,
141
v August 31, 2015 94 War or Dates
Place of Death Hospital, Institution or
4 1 City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
M• anner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
`
E Philip J. Gara, Dr.
Address
iv 318 Broadway Fort Edward 12828
Death Certificate Filed District Number5775 Reg tNumber
• City, Town or Village Fort Edward -
4: ❑Burial Date Cemetery or Crematory
September 4, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
4.5
❑ Disinterment Date Cemetery Address
4
tAk❑ Reinterment
Date Cemetery Address
P• ermit Issued to Registration Number
N• ame of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
x Permission is he b granted to dispose of the human a described abbo� as indicated.
Date Issued `� Registrar of Vital Statistics dli
, v
�jp'j� ( ignature)
`?District Number55 Place
am. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
P‘'ile ec,1 Ld e nk x1,r to
. ., Date of Disposition 09/04/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) n (lot number) (grave number)
Name of Sexton or Person in Charge of Premises I iv,o'1- (tv„elle
(please print)
Signature cL�� a�sL�� Title C re.nk40(y OSsi
(over)
DOH-1555 (02/2004)