Anderson, Clarence NEW YORK STATE DEPARTMENT OF HEALTH c ''
Vital Records Section Burial - Transit Permit
iiiiil Name First Middle Last Sex
C1=t1-i. --e Richard Anderson Male
> Date of Death Age If Veteran of U.S. Armed Forces,
March 13, 2013 67 War or Dates Yes 1966-68
Place of Death Tn. of Moreau Hospital, Institution or 60 Fawn Road
City, Town or Village Street Address Cansevoort, NY
Manner of Death L$Natural Cause El Accident 0 Homicide 0 Suicide ri Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Roberta Miller MD
Address
16 Crimson Oak Court Schenectady New York
Death Certificate Filed District Number Register Nu ber
i]ig City, Town or Village Tn. of Moreau �,5701
Date Cemetery or Crematory
CI Burial March 14 , 2013 Pine View Crematory
Address
. Cremation 21 Quaker Road Queen.sbury, New York
Date Place Removed
g ElU❑Removal and/or Held
—• and/or Address
5' Hold
0 Date Point of
ikID Transportation Shipment
a by Common Destination
Carrier
Disinterment Dafe Cemetery Address
..... Reinterment Date Cemetery Address
Permit Issued to M. Kilmer Funeral Home
Registration Number
?s' Name of Funeral Home 01078
>> Address
136 Main St. South Glens Falls, New York 12803
> ; Name of Funeral Firm Making Disposition or to Whom
f="" Remains are Shipped, If Other than Above
a Address
iiiiiiii Permission is hereby granted to dispose of the human remains described above as indicated.
in Date Issued 3-1 -1 3 Registrar of Vital Statistics 'I ,� I 1 l/ • :1 LLLL1.-�
(si nature)
�( Place Tn. of Moreau
District Number 3 - i I I3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
faZ
Pt,lIt_
Date of Disposition �1S13 Place of Disposition VOL‘,-- rrF
(address)
ILl
CO
ti (section) ,14,--v
lot niumberl (grave number)
0 Name of Sexton o erson in a of Premises _)e o t ervl.-�'
g (please print)
Signature .. / /4a ,s.Y
(over)
DOH-1555 (9/98)