Harder, Anna NEW YORK STATE DEPARTMENT OF HEALTH ; fa?
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anna Mae Harder Female
Date of Death Age If Veteran of U.S. Armed Forces,
• August 2, 2014 75 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Washington Center
Manner of Death El Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Edit Masaba, MD Dr.
Address
200 Main Street Greenwich, NY 12834
Death Certificate Filed District Number Register Number
City, Town or Village Argyle
❑Burial Date Cemetery or Crematory
August 5, 2014 Pine View Crematory
❑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
Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
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
Address
Permission is hereby granted to dispose of the human rem ns described above as indicated.
' Date Issued t) J.-N Registrar of Vital Statistics
/ (signature)
District Number Sig; Place mtlu
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/05/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises « r- &IWO
8: (pl se print)
Signature Title CPChft
(over)
DOH-1555 (02/2004)