Hohman, Edith 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
p Manner of Death n Natural Cause Accident nHomicide El Suicide Undetermined Pending
Circumstances Investigation
WMedical 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
❑Entombment
11/04/2019 PineView Crematorium
Address
FRICremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
0 and/or and/or Held
~ Hold Address
N
O
4. Date Point of
N Transportation
7 by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment 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
Remains are Shipped,If Other than Above
Address
W
I' 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:
Z Date of Disposition Place of Disposition
W (address)
W
(section) ,� (lotnumber/ (grave number)
G Name of Sexton or Person in Charge of Premises
tease print)
z
W Signature lei 7 Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on ! , 20
4
Pine View Cemetery Representing the funeral home named`lop lbria�l pe mit
Official Funeral Directors Reg.or License# =-� —