Hughto, Eugene NEW YORK STATE DEPARTMENT OF HEALTH--** % # 2 y-2
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eugene Alexander Hughto Male
Date of Death 0 3/2 9/2 01 6 Age 8 5 If Veteran of U.S. Armed Forces,
War or Dates 1 957-1 968
j - Place of Death Hospital, Institution or
WCity, Talmo orVillage Queensbury Street Address Warren Health Facility
a Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 1=1 Pending
IliCircumstances Investigation
ui Medical Certifier Name Title
CI Roslyn Socclof MD
Address
42 Gurney Ln. Oueensbury, NY 12801
Death Certificate Filed D ri�N umber Reg,ster, Number
City, Top or Village Queensbury S ---
❑Burial Date Cemetery or Crematory
03/30/2016 Pine View Crematory
0 Entombment Address
Queensbury, NY 12801
®Cremation
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
i= Hold
CO _
0 Dat Point of
Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Funeral Home 01 078
Address
136 Main St. So. Glens Falls, NY 12803
Name of Funeral Firm Making.Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
CC
ti
CL Permission is hereby granted to dispose of the human r mains described above as indicated.
Date Issued l t(Registrar of Vital Statistics C.\__ Q. CAI . 2-CJ�
-� (signature)
District Number '' Place ( Ot_e_r-N 6-c C___ L.„1/4..sz jii..\,..sb
I certify that the remains of the decedent identified above were disposed of in accor ance th this permit on:
tip Date of Disposition N II '/(, Place of Disposition 'fart i _. Ci4mt6iff-N,
a (address)
ILI
CO
CC (section) A - (lot number) (grave number)
""
a Name of Sexton or Person in Ch ge of Premises ' r� - ,�lam,�^~ir
Z (please print)
Signatureif Title (17141ilif'�,
(over)
DOH-1555 (02/2004)