Wilson, Marc NEW YORK STATE DEPARTMENT OF HEALTHs v' 6-7Z
Vital Records Section Burial - Transit Permit
;,<; Name First Middle Last Sex
rc
Date o• f Death AgeAnthony GeralfVeteran of U.S. 'lson
Armed Forces, Male
September 6, 2014 35 War or Dates
Place of Death Hospital, Institution or
q'< City, Town or Village Glens Falls Street Address 60 Third Street
xk Manner of Death IL.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Timothy Murphy,
Address
_' 52 Haviland Ave Glens Falls, NY 12801
0. Death Certificate Filed District Number , .71 Register�uppber
P
City, Town or Village Glens Falls AU L 4 �
s❑Burial Date Cemetery or Crematory
0i. September 11, 2014 Pine View Crematory
- ❑Entombment Address
F ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
{-4
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
IllReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
j X _ Address
e .: 136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
fr
Permission is hereby granted to dispose of the human remains described above as indicated.
�
Date Issued %Q j/W Registrar of Vital Statistics (A) cAAj '`.Q- LA)-- -A —
�,' (signature)
District Number 560 1 Place 6 (Q S V-0, k.k. c At y
a
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/11/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises rat4t- S40M
(pease print)
Signature �� Title til n1I1T t
(over)
DOH-1555 (02/2004)