James, Wilfred NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section I 1, Burial - Transit Permit
J'"'," Name First Middle Last Sex
-.1.4 Wilfred Willard James Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 14, 2014 89 War or Dates
• Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 162 Fort Edward Road
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 1-1 Undetermined ❑ Pending
Circumstances Investigation
" ' Medical Certifier Name Title
Joseph C. Mihindu, M.D. Dr.
Address
52 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register
Register Number
City, Town or Village Moreau v
❑Burial Date I k Cemetery or Crematory
i Marchi 2014 Pine View Crematory
i ❑Entombment Address
El Cremation Quaker Road Queensbury,NY 12804
u . Date Place Removed
• °.❑ Removal
and/or Held
.< and/or Address
Hold
Date Point of
,, ❑Transportation Shipment
•• by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
': Date Cemetery Address
,. ❑ Reinterment
Permit Issued to Registration Number
4t Name of Funeral Home M.B. Kilmer Funeral Home 01078
.,44 4
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
n
Address
Permission is hereby granted to dispose of the human r ains described above as indicated.
Date Issued 3) 1 -/ /4 Registrar of Vital Statistics 01- 1Lt2_ ,(Ju I
n (signature)
District Number Lis 1"Z Place 3,51 K� N a c_DS CD. 1/o icau iucj Os' '
. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: '" "
Date of Disposition 034/2014 Place of Disposition Quaker Road Queensbury,NY 12804 /vit t/,�-•/C'a ,4,/
(address)
,` / (section) 64.4num er) 1 (grave number)
Name of Sextop��6 Pe on • rge of Premises �
(please print) l/
Signatur 41 ( Title ct , ,L %-
(over)
DOH-1555 (02/2004)