Bodner, Alexander NEW YORK STATE DEPARTMENT OF HEALTH ` -* Z
Vital Records Section Burial - Transit Permit
77
Name First Middle Last Sex
= Alexander Andrew Bodner Male
Os fq
Date of Death Age If Veteran of U.S.Armed Forces,
y, December 1, 2013 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 39 Mechanic Street
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0Undetermined ri Pending
Circumstances Investigation
'? Medical Certifier Name Title
Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
�' Death Certificate Filed District Number Regist ber
F City, Town or Village Fort Edward
❑Burial Date Cemetery or Crematory
December 2, 2013 Pine View Crematory
❑Entombment Address
;®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
in Disinterment
Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
0,,' Name of Funeral Home M. B. Kilmer Funeral Home 01079
Zt Address
x,
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
r Address
Permission is her y ranted to dispose of the huma ains describ•d abo as indicated.
Date Issued . Registrar of Vital Statis ,t , �'l`_ ,,,.0l
r_--'T'_'_ (signa
District Number f Place �f tin
Z i("
`` I certify that the remains of the decedent identified ove were disposed of in accordance with this permit on:
Date of Disposition 12/02/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) //(lot number) r (grave number)
= Name of Sexton or Person in harge of remises fir4 { -.p./40
(please print)
Signature ' Title fl
(over)
DOH-1555 (02/2004)