Hossann, Dennis t e ;.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ini Name First Middle Last Sex
Dennis D Hossann Male
Date of Death Age If Veteran of U.S. Armed Forces,
EI 03/18/2017 71 years War or Dates
j- Place of Death Hospital, Institution or
City, TD6iKdCD(r Xjtll( �( Glens Falls Street Address Glens Falls Hospital
Manner of Death❑ [�
Natural Cause ❑Accident ❑Homicide 6uicide ❑Undetermined ❑Pending
IIICircumstances Investigation
ill Medical Certifier Name Title
P. Stephen Perzzelli M D
Address
100 Park Street Glens Falls, N Y 12801
Mii Death Certificate Filed District Number Register Number
iiig City, TUXXr)QX1X C Glens Falls 5601 167
giii ❑Burial Date Cemetery or Crematory
03/20/2017 Pineview Crematory
niii❑Entombment Address
!iilligCremation Queensbury, N Y 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
I= Hold
IA
0 Date Point of
ItE Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
liiiiiiii Permit Issued to Registration Number
Name of Funeral Home 4yt.5 ?,f Pere,/ )-i)c 1€. yg
Address ,/ �(,/"7 5/10-r evit Ave, Ca6)1,j l i, j ! its ZZ
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
it
111
1 Permission is hereby granted to dispose of the human remains described above as indicated.
II Date Issued 03/20/2017 Registrar of Vital Statistics (.") L'.3
(signature)
District Number 5601 Place Glens Falls j Ai V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILt Date of Disposition y-zop Place of Disposition 2,) 7 ) Cia-n-re, j 1 Ai
2 (address) /
UI
CA
CC (section) /(lot number) (grave number)
Ci• Name of Sexton or rs I Charge of Premises -3 u-1 ' apt ' rne.-v 4
(please print)
• Signature Title C 2..1,4 .-71-0,—
(over)
DOH-1555 (02/2004)