Van Sittert, Arthur NEW YORK STATE DEPARTMENT OF HEALTH , ,. A ft I g 7
Vital Records Section Burial - Transit Permit
Name Figur Middle Last Sex
Van Sittert Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/10/2015 65 years War or Dates1969-1972
j- Place of Death Hospital, Institution or
W CityXnXslNe Amsterdam Street AddressSt. Marys Hospital
0 Manner of Deatly❑Natural Cause ❑Accident ❑Homicide ❑Suicide ElUndetermined ElPending
1,11 Circumstances Investigation
Lu Medical Certifier Name Title
Phillipgqild Kasofsky
427drbuy Park Ave, Amsterdam, New York 12010
Death Certificate Filed District Number Register Number
CityXnge Amsterdam 2801 87
❑Burial Date Cemetery or Crematory
03/16/2015 Pine View Crematory
['Entombment Address
' ❑Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
1....
Hold
CA
P. Date Point of
Transportation Shipment
G1 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homg/1b Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward, Ny 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above •
2 Address
L
W.
.C` Permission is hereby granted to dispose of the human re 03/12/2015 n descried - ode as indi:- - d.
Date Issued Registrar of Vital Statistics .!��"'✓ 0 -
(signature)
District NumbTr801 Place Amsterdam
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
illDate of Disposition /`i. is' Place of Disposition , Uti, CA,,,,,t-o,..
2 (address)
LU
V1
CC (section) �/ (lot number (grave number)
Name of Sexton or Person in harge f Premises G' ' -.1004fiir
2 please print)
ta
alE T
;: Signature Title Y` a-
(over)
DOH-1555 (02/2004)