Elgot, Jeffrey Lamar NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jeffrey Lamar Elgot Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/21/2020 57 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Nyack Village Street Address Montefiore Nyack Hospital
j3 Mannerof Death ❑X Natural Cause ❑Accident ❑Homicide Suicide Undetermined Pending
UJIV Circumstances Investigation
W Medical Certifier Name Title
G Besher Kabak MD
Address
160 N Midland Ave,Nyack Village,New York 10960
Death Certificate Filed District Number Register Number
City,Town or Village Nyack Village —74324 304
Burial Date Cemetery,Crematory or Facility Name
05/01/2020 Pine View Cemetery and Crematorium
Entombment Address
K❑Cremation Queensbury,New York
Donation
z Removal Date Place Removed
and/or and/or Held
H N Hold Address
O
IL Date Point of
EA ❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Clark Funeral Home Inc 00340
Address
2104 Sawmill River Rd,Yorktown Heights,New York 10598
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
LU
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/28/2020 Registrar of Vital Statistics (Patricia Evans(-'lectron-af Signed
(signature)
District Number 4324 Place Nyack Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ SI1 110 Place of Disposition Z Date of Disposition position �
Uj (address/
X.
W
N (section) (I numb / (grave number)
G Name of Sexton or Person in Charge f Premises �'ta
�j lease print)
W Signature f✓ Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) j 13 r)7 5
1
Receipt
Human remains of delivered on , 20
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Pine View Cemetery Representing the funeral home named on budqqermit
Official Funeral Directors Reg.or License#