Hohman, Edith B. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Edith B Hohman Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/01/2019 95 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death NIJC�jatural Cause Accident Homicide Suicide Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
0 Brandii Baker NP
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 472
Burial Date Cemetery,Crematory or Facility Name
11/04/2019 PineView Crematorium
Entombment Address
Cremation Queensbury Town, New York
Donation
Z Removal Date Place Removed
and/or and/or Held
�- Hold Address
U)
O
IL Date Point of
U) Transportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann, New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/04/2019 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H \�
Z Date of Disposition Place of Disposition
W
2 (address)
W
U) (section) ,� (lot number) (grave number)
IIX
� Name of Sexton or Person in Charge of Premises r"
lease print/
W Signature lei Title
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New York State
Department of State
NEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:
Nov. 02, 2019 Number: lC..o/I
Crematory Name: L F V-k c 'Qlrm jcI
Address: 71 ���+Vlk(L (ZD kp �1 pi a H (150 hone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where
they are subjected to intense heat and flame. The heat and flame will incinerate and consume everything except bone and metal,
which are all that will be left after cremation.
Following cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
chamber,but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from
the remains and the incidental and foreign material will be disposed of as required by law. The cremated remains will be mechanically
pulverized into small pieces and placed into a designated container or urn. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
OPENING OF THE CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to confirm the
identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. If
human remains are delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the
crematory will require that the remains be moved into a suitable container before it accepts the remains. The opening of a
container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: Edith B. Hohman Marital Status: Widowed
Last Known Address: 1 1 1 0 Copeland Pond Rd. , Fort Ann, NY. 12827
Placeof Death: Glens Falls Hospital, 100 Park St. , Glens Falls, NY.
Sex: El M IMF Age: 95 DOB: 0 2/0 6/19 2 4 Date of Death: Nov. 01 , 2019 Estimated Weight:
Description of casket/container in which remains will be delivered.Florence Casket Co.
wnnd, wnnd r-mmpnsi tP hasp, cardboard top_
PERSON IN CONTROL OF DISPOSITION
(P rson s in control of disposition, initial ONE of the following)
'I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
Edith B. Hohman
(Name of DeceaserQ
D03-1898-f(Rev. 08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: / Description: EWj5:;::jW 71e)Z
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner;
3. Any surviving child eighteen years of age or older;
4. A surviving parent;
5. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who is/are closest in relationship to the deceased;
8. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act;
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Section 4201(7).
®A(In'ial AL THREE of the following)
-�/We hereby affirm that the body of the deceased does not contain a battery, battery pack,power cell,radioactive implant,
or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
these ite prior to cremation may result in harm to the crematory and crematory personnel.
® I/We affirm that instructions have been given to Bruce K. Mason
(Funeral Director Name)
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
deceased wishes to preserve. PI p t 11 go
(Crematory Name)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
cPKI/We
ith the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
hereby authorize fro V1
(Crematory Name)
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Bruce K. Mason
Address: P.O. Box 277, Fort Ann, NY. 12827 Phone518-639-5252
The cremated remains of deceased will be disposed of as follows:
Return to family.
If for any reason the person named above does not take possession of the cremated remains,
1 hi EyAf o is authorized to give possession of
(Cramaov Name)
the remains to Mason Funeral Home by delivery
(Funeral Home Nane)
in person or by registered mail.
Edith B. Hohman
(Name of Deceased)
DOS-1898-f(Rev.08/15) Page 2 of 3
Authorization for Cremation and Disposition
(I tia th flowing)
I/We understand that if the remains are not claimed within 120 days of cremation,
l i gf44 " may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERIURN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
AgAn urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
w �� will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was b provided Bruce K. Mason P Y was executed at
(Funeral Director Name)
Mason Funeral Home
(Funeral Home Name)
18 George St. , Fort Ann, NY. 12827
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s)identified below is/are the person(s)in control of disposition,who by signing this Authorization Form,attests)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the fo going.
Signed this 02 day of Nov. 019 l
— typed or Printed Name ignature
1181 Copeland Pond Rd. , Fort Ann, NY. 12827
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Bruce K. Mason ,/,/�►r�
(Funeral nirentor Typed r Prtntad Ner" (Funeral Dirertnr Signaf im)
Registration Number
Edith B. Hohman
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 3 of 3