Worth, John fi l S a -
NEW YORK STATE DEPARTMENT OF HEALTH , _ 11Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
tA, John Allen Worth Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 29, 2012 43 War or Dates
-1 Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address 24 Sams Hill Road
Manner of Death El Natural Cause 0 Accident 1=1Homicide 0 Suicide rulUndetermined cyn Pending
Circumstances Y-4 Investigation
Medical Certifier Name Title
Max Crossman M.D. Dr.
Address
zwt kim
65 Poultney Steet Whitehall, NY 12887
Death Certificate Filed District Number Register Nyber
iic7.;, City, Town or Village
❑Burial Date Cemetery or Crematory
March 30, 2012 Pine View
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
' _ Carrier
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
F Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
, Address
WA
123 Main St., Argyle NY 12809
0,, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h reb granted to dispose of the human remains described above as indicated.
Date Issued 0 Registrar of Vital Statistics 0 "`lj qnCe.t( -
MA
u= (signature)
01 District Number(5 Place
h; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/30/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
a (section) /fir (lot number) (grave number)
, Name of Sexton or Perso in Charge of Premises (6reA'4p�-l- SLNiltt) t (please pent)
Fa- Signature �� 1)-- Title Cf€1111-.oD-
(over)
DOH-1555 (02/2004)