Hitchen, Ann NEW YORK STATE DEPARTMENT OF HEALTH � 7 1
Vital Records Section ` , Burial - Transit Permit
Name First Middle Last Sex
Ann Jones Hitchen Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 10, 2015 74 War or Dates
Place of Death / Hospital, Institution or
City, Town or Village $-ray(J/�1 .Q Street Address 31 Quaker St.
Manner of Death Natural Cause Accident Homicide Suicide Undetermined El Pending
Circumstances Investigation
s Medical Certifier Name Title
Hogankamp Peter, Dr.
Address
10 Commons St. Rutland, VT 05701
Death Certificat- ,ti District Number Register Nu••er
a Ci Town •,A'a1t• tit(1/ �.- J� aim'
do
���Burial l ate Cemetery or Crematory
June 11, 2015 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
,- Date Place Removed
Removal and/or Held
and Address
Hold/or
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name 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
Permission is her by ranted to dispose of the human rem ' s descri•i boy indicated.
s
Date Issued 6 /1 /,� Registrar of Vital Statistics .,be(,,,
(signature)
District Number 5 7A5 Place ��'/itto �f� _/ 3
y,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,, Date of Disposition 06/11/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) ,,��., •- £..
(lot number) (grave number)
NA, Name of Sexton or Person in Ch ge of Premises GI,.
(please print)
Signature Title ri ''tei"t_
(over)
DOH-1555 (02/2004)