Haff, June NEW YORK STATE DEPARTMENT OF HEALTH„ I # /C t.3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
June _ Cameron Haff Female
Date of Death Age If Veteran of U.S. Armed Forces,
_- May 21, 2012 90 War or Dates World War II
Place of Death
Hospital, Institution or
`` City, Town or Village Hartford Street Address 7251 State Route 40
.. Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
'. Medical Certifier Name Title
Thomas Coppens, Dr.
Address
3 Iron Gate Center Glens Falls 12801
Death Certificate Filed District Number Register Number
. City, Town or Village Hartford
Date
El Cemetery or CrematoryFr May 23, 2012
Morningside Cemetery
-❑Entombment Address
®Cremation Hartford,NY 12838
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
= I Ell Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
123 Main St., Argyle NY 12809
_ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
10
, Permission is h reby ranted to dispose of the human rem i described , :• • 'ndicated.
Date Issued 5 �2 \22— Registrar of Vital Statistics
(signature)
$` District Number Place 4,(i � ? ' l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/23/2012 Place of Disposition Hartford,NY 12838
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge o Premises 4,,. SC tt
/ (please print)
Signature ;1 ' Title at,IPI1 L
(over)
DOH-1555 (02/2004)