Middleton, Harold NEW YORK STATE DEPARTMENT OF HEALTH t9-)S
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harold Elmer Middleton Male
Date of Death Age If Veteran of U.S. Armed Forces,
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October 25, 2014 93 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Washington Center
s Manner of Death X❑ Natural Cause 111 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Edit Masaba, MD Dr.
Address
35 Gilbert Street Greenwich, NY 12834
• Death Certificate Filed District Number_ Register Number
• City, Town or Village Argyle SC)
❑Burial Date Cemetery or Crematory
October 27, 2014 Pine View
• ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
I Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
xi III
A El Reinterment
Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
_; Address
r 82 Broadway, Fort Edward NY 12828
vm Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereb granted to dispose of the human-re ins des ribed above a in icated.
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Date Issued ) - .�Registrar of Vital Statistics ,w � \&\L‘' ,1Li.i�
(signature)
• District Number `j� Place V r)wAr-N Cs\ l
ti
• I certify that the remains of the decedent identified above were dispose `of in accordance with this permit on:
Date of Disposition 10/27/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) lot number) (grave number)
r Name of Sexton or Person in Charge of Premises A+y+
(please print)
x Signature / Title Crilikre
(over)
DOH-1555 (02/2004)