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Harrington, Arvid NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit <': Name First Middle Last Sex Arvid F. Harrington Male »' D• ate of Death Age If Veteran of U.S. Armed Forces, December 1 1 , 2012 76 War or Dates P• lace of Death Hospital, Institution or City, Town or Village Fort Ann Street Address 89 Buttermilk Falls Rd 21 Manner of Death©Natural Cause 0 Accident 0 Homicide 0 Suicide 111 Undetermined ri Pending al Circumstances Investigation g Medical Certifier Name Title Dr. Eric Pillemer Address 100 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number is City, Town or Village Date Cemetery or Crematory ❑Burial December 12, 2012 Pine View Crematory Address ®Cremation Quaker Road Oueensbu y Ny 12804 Date Place Removed t❑Removal and/or Held . and/or Address O Hold O Date Point of ei Q Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address >: Permit Issued to M.B. Kilmer Funeral Hom9 Registration 01 078 Number Name of Funeral Home €': Address 136 Main Street South Glens Falls, NY 12803 ; Name of Funeral Firm Making Disposition or to Whom '" Remains are Shipped, If Other than Above ri Address : Permission is hereby granted to dispose of the human re -ins described abo dicated. s' Date Issued Registrar of Vital Statistics _ ,,, _ �. ! t1 (si. !ture) €; District Number Place < L/. j , i• . `)--2-7 / I certify that the remains of the decedent identified above were dispo e. of in accordance with this permit on: Ate-sC.,6.,/ ILIZ Date of Disposition 1 2/12/20 -mace of Disposition Quaker Road Queensbury, NY 1 2804 2 (address) W 11 (section) fI% (lo number) (grave number) GName of Sexton or rso n C f Premises 56 h�/ir/17 d z (please print) L.4: Signature d Title C4410A94-4G A'S (over) DOH-1555 (9/98)