Hoyt, Terry NEW YORK STATE DEPARTMENT 0 Ft ALTH 4 fp
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Terry E Hoyt Male
Date of Death Age If Veteran of U.S.Armed Forces,
. April 6, 2016 IOJ� War or Dates
Z Place of Death Hospital, Institution or
w City,Town,or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined ❑ Pending
Circumstances Investigation
(� Medical Certifier Name Title
Dr. Max Crossman MD
Q Address
Whitehall Health Center, Poultney St. , Whitehall, New York 12887
Death Certificate Filed District Number/6/ Register NyM
City,Town or Village Glens Falls (� 7
❑Burial Date Cemetery or Crematory
April 8, 2016 Pineview Crematorium
❑Entombment Address
❑X Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 El Removal and/or Held
and/or Address
' Hold
Date Point of
0 0 Transportation Shipment
D. by Common Destination
Carrier
.0. Date Cemetery Address
. Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
ix Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicfted.
Date Issued f -7 1 )6 Registrar of Vital Statistics t>'JtAiry‘A., UO
(signature)
District Number S 6 Q I Place Glens Falls,New York
F 1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 04/08/2016 Place of Disposition Pineview Crematorium
W (address)
(section) (lot numbs (grave number)
d Name of Sexton or Person in Charge of Premises Alf
4 1,— 3e ►•tA-
(ease print)
W ',!
Signature chrkTitle Mik "k i(
(over)
DOH-1555 (02/2004)