Yerdon, Rose NEW YORK STATE DEPARTMENT OF HEALTH '‘
Vital Records Section Burial - Transit Pe mit
Name First Middle Last Sex
Rose Marie Yerdon Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 16, 2013 56 War or Dates
Place of Death Hospital, Institution or
r. City, Town or Village Street Address 4176 County Route 30
Manner of Death 0 Natural Cause 0 Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending
Circumstances Investigation
'' Medical Certifier Name Title
Gordan Nicholas Kuhar,
Address
3050 Route 50 Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Numbe
City, Town or Village SNVZV P1 I , ESQ C 16
a❑Burial Date Cemetery or Crematory
May 23, 2013 Pine View Crematory
❑Entombment:orrl iv, 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
Is Carrier
Date Cemetery Address
❑ Disinterment
❑ Renterment Date Cemetery Address
_ Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
123 Main St., Argyle NY 12809
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 re awns described bove as indicate .
Date Issued iit j7/_5 Registrar of Vital Statistics / �Q'4 "" .6�� l
9 / G;C��� 1 (signature)
District Number 7o.j Place A=a Z.& ,J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
3 Date of Disposition 05/23/2013 Place of Disposition Quaker Road Queensbury,NY 12804
x; (address)
(section) z flot n mber) c (grave number)
�- l
Name of Sexton or Per n in Charge Premises ris'7 hr
L. (plddase print)
,X Signature Ira•- Title Cr t
(over)
DOH-1555 (02/2004)