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Howley, Theodore
9?L( NEW YORK STATE DEPARTMENT OF HEALTH - Burial - Transit Permit Vital Records Section x _ _"�, Name First Middle Last Sex Theodore Howley Male akit :1:7.4. Date of Death Age If Veteran of U.S. Armed Forces, December 4, 2018 71 War or Dates Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address 159 Pitcher Road Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined ri Pending Circumstances Investigation Medical Certifier Name Title Lynn M. Keil, Address 161 Carey Road Queensbury, NY 12804 Death Certificate Filed District Number Register Number City, Town or Village Queensbury (oc� ) (n g 0 Burial Date Cemetery or Crematory December 7, 2018 Pine View Crematory ,❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held �, and/or Address Hold . Date Point of it 4 v❑Transportation Shipment by Common Destination Carrier 3:12 ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number v Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 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 rem in described abo a as indicated. Date Issued1 -\—1 Irel Registrar of Vital Statistics (_ CA, Cjs.S,r /` signature) 4 District NumbetLo{--) Place / O LSZ-,r-, d-C 0 MS } I certify that the remains of the decedent identified above were disposed of in accor•- - ith this permit on: „ Date of Disposition 12/07/2018 Place of Disposition Quaker Road Queensbury,NY 12804 Rik, vc,w Gr.v..e4cry (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises -17th►4JY S%u ic-c,5 (please print) Signature . 0f° / Title C.-Xt./tick r (over) DOH-1555 (02/2004)