Harrington, Edward NEW YORK STATE DEPARTMENT OF HEALTH 0 lk, -it )65 )
Vital Records Section Burial - Transit Permit
4••- Name First Middle Last Sex
Edward Ellworth Harrington Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 24, 2014 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
A► Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
1., Circumstances Investigation
Medical Certifier Name Title
Michael Adams, Dr.
Address
10154 Saratoga Raod Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
; City, Town or Village Glens Falls .j 60 1 ) £-(5
❑Burial Date , r Cemetery or Crematory
k _7/�71//� Pine View Crematory
r=❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
as Carrier
Date Cemetery Address
III Disinterment
Date Cemetery Address
❑ Reinterment
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 hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 ( 26 I. 1 y Registrar of Vital Statistics (A) C;t, p, k./l
UU (signature
District Number 56 0( Place 6 CAS rA k `S N v
j r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3I )))y Place of Disposition 21 Quaker Road Queensbury,NY 12804
1 (address)
. (section) (1 umber) (grave number)
0 �
' Name of Sexton or Per n in Char a of Premises `hru L --144--
//r% (please print)
P Signature Title G`v( t�►L
(over)
DOH-1555 (02/2004)