Sherwood Sr, Edward i `! if VI C
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edward R(Agse\\ Sherwood Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 6, 2014 76 War or Dates
Place of Death Hospital, Institution or
! , City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
• Manner of Death X❑ Natural Cause E Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
t Medical Certifier Name Title
Bernardo R Villajuan, Dr.
Address
161 Carey Road Queensbury, NY 12804
_ i Death Certificate Filed District Number Register Number
r , City, Town or Village Fort Edward 575
.a❑Burial Date Cemetery or Crematory
November 7, 2014 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
A ❑ Removal and/or Held
and/or Address
Hold
Date Point of
0 ❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
z: Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 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 he eby r ted to dispose of the human r ins described bove indicated.
Date Issued 7 Registrar of Vital Statistic y11 p
(signature/�
District Numbers 75 Place / 5)Ak) 7c� �?� �R.//
i, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition 11/07/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
s s.;
it (section) (lot number), (grave number)
Name of Sexton or Person i Charg of Premises i'L 3as dt
t ( ease print)
Signature Title :Pit✓vff'-i
(over)
DOH-1555 (02/2004)