Bossonis, Evan Walter NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Evan Walter Bossonis Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/19/2020 57 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
UCircumstances Investigation
Q Medical Certifier Name Title
Aqeel Gillani MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 130
❑Burial Date Cemetery,Crematory or Facility Name
03/23/2020 Pine View Crematory
Entombment Address
RI Cremation Queensbury Town,New York
Donation
OZ Removal Date Place Removed
and/or and/or Held
H N Hold Address
O
a. Date Point of
to Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Otherthan Above
Address
IM
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/22/2020 Registrar of Vital Statistics WpAert,4hdrewCurtzr(EYectronkalfySi rned�
(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 3�%?p Place of Disposition
W t` (�,��o r
2 (address)
W
NIM (section) (lot number) (grave number)
GName of Sexton or Person in Charge of Pre ses
Z (please print)
W Signatures—? Title
DOH-1555(07/18)p 1 of 2
w ..
Public Health Law Sec. 4145(2b) 013455
Receipt
Human remains of delivered on , 20
Piw Cemetery Representing the funeral home named on burial permit
Ohiicial Funeral Directors Reg.or License#