Holmquist, Keith 30
NEW YORK STATE DEPARTMENT OF HEALTH 4 71 r i
,I
Vital Records Section Burial - Transit Permit)
Name First ` r Middle Last Sex
Keith Brian Holmgi ii st Male
Date of Death Age If Veteran of U.S. Armed Forces,
S 06(13 58 War or Dates 1972-1974
}- Place of Death Hospital, Institution or
City, Town or Village Albany Street Address 113 Holland Avenue
IIIManner of Death Natural Cause El Accident El Homicide EI Suicide Undetermined Pending
W. Circumstances Investigation
ig Medical Certifier Name Title
Ct Roberta Flesh MD,
113 Holland Avenue Address Albany, N, 12208
'> Death Certificate Filed District Number 198 Register Number 068
City, Town or Village Albany
❑Burial Date _ , 1 Cemetery or Crematory
Db ! P S12o'3 Pine U; e.0 Cc4e(y)4 -
❑Entombment Address
;< [§Cremation Qu.te vbt,.(- r�{
1
Date Place Removed
Z Removal and/or Held
9❑and/or Address
F4 Hold
to
O Date Point of
s: Transportation Shipment
Es by Common Destination
Carrier
Q Disinterment Date Cemetery Address
:: ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home, 01078
Address
136 Main St., S. Glens Falls, NY 12803
NI Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
o
w
fls' Permission is hereby granted to dispose of the human remains described above as indicated.
_ Date Issued 5/26/13 Registrar of Vital Statistics
James H. Arrington
>
DVAIT, 113 Holland Avenue, Albany New Yofkg1
District Number 198 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
a
lLI Date of Disposition S/29 0Place of Disposition ,, •C,y,.clom,,.
(address)
ILI
1fl
iZ (section) kridpit-
t num er) (grave number)
0
Name of Sexton or Person in Chargeof Premises Sii4rr
giL, (pleas print)SignatureTitle C M)1V
(over)
•
DOH-1555 (02/2004)