Patton, LUther t .. N 44 Z Liii(
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Fist MiddleLaat t Sedale
Luther Alfred Pon
Date of Death Age If Veteran of U.S. Armed Forces,
04126;2013 95 years War or Dates
t- Place of Death Hospital, Institution or
Z City, X ConifIgre Saratoga Springs Street Address Wesley Health Care Center Inc.
ci Manner of Death Natural Cause ❑Accident ElHomicide ❑Suicide ri❑Undetermined ❑Pending
tit Circumstances Investigation
tu Medical Certifier Name Title
t Austin Tsai M D
A 't�awrence St., Saratoga Springs, N Y
Death Certificate Filed District Number Register Number
City, IdagolMigie Saratoga Springs 4501 196
['Burial Date Cemetery or Crematory
04/30/2013 - Pine View Crematory
( ? 0 Entombment Address •
'*]Cremation Queensbury N Y .
Date Place Removed
Z Removal and/or Held
2❑and/or Address
.a, Hold
Date Point of
iri Transportation Shipment
0 by Common Destination
Mii Carrier •
Disinterment Date Cemetery Address
•
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.b. Kilmer Funeral Home 01078
- E Address
82 Broadway, Fort Edward, N Y 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
E. Address
I
Permission is hereby granted to dispose of the human remai scr'bed ab
ye as indicated.
iiiiiiiiii Date Issued 04/29/2013 Registrar of Vital Statistics t - -4-tiLtur4.
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k.'.:>_:
ILI Date of Disposition S-1i3 Place of Disposition 2tata 1.nctdrera,
(address)
Ili
C
CC (section) 41.0
lot numbe�y����� (grave number)
Name of Sexton or Person in Charge f Premises ``J
(please print)
Signature Title C'rLPr^'tYk L-
(over)
DOH-1555 (02/2004)