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Rothbart, Anna NEW YORK STATE DEPARTMENT OF HEALTH it GOO Vital Records Section Burial - Transit Permit f Name First Middle Last Sex Anna Marie Rothbart Female Date of Death Age If Veteran of U.S. Armed Forces, 0 9/2 2/2014 9 2 War or Dates 1- Place of Death Hospital, Institution or Gity-Town er-pillage Argyle Street Address 1 01 Ti l f ord Road 0 Manner of Death Undetermined Pending ©Natural Cause �Accident D Homicide 0 Suicide ri Circumstances Investigation tu Medical Certifier Name Title Kevin Gallagher Address 79 North Street, Granville, NY 12832 Death Certificate Filed District Number S� Register Number City, Town or Village ilii ElBurial Date Cemetery or Crematory 09/24/2014 Pine View Crematory NIIII ['Entombment Address r ®Cremation 21 Quaker Road Quec bur NY 1 2804 Date lace Fe'moved Z❑Removal and/or Held and/or Address F= Hold U 0 Date Point of Transportation Shipment a by Common Destination iN Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address <: Permit Issued to M.B. Kilmer Funeral Home Registration Number Name of Funeral Home 01 079 Address 82 Broadway Fort Edward, NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address 1 Illy '`` Permission is hereby granted to dispose of the human remains described above as indicated. in Date Issued 'I a 4 Jôi Registrar of Vital Statistics d"`t t kfAikon (signature) il District Number S ti 5-6 Place _ ICE 1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 3a Date of Disposition 1+1(o(P1 Place of Disposition � -i L y� r -- 2 (address) la CA >l (section) (lot number) (grave number) f912velf Name of Sexton or Person in Charge of Premises ^r �'` lease print) �/ i Wg Signature L'�' _A-- Title (over) DOH-1555 (02/2004)