Hayes, John lb .g011
NEW YORK STATE DEPARTMENT OF IltALTH
Vital Records Section _; . x. Burial - Tr nsit Permit
Name First Middle Last Sex
John Edwin Hayes Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/04/2016 ',,.67 years z, War or Dates 1968-1970
}•: Place of Death Hospital, Institution or
a City, TM=Vitmoc Glens Falls Street Address Glens Falls Hospital
Manner of Death ,Natural Cause 0 Accident El Homicide D Suicide ElUndetermined Pending
Uf Circumstances Investigation
10
tu Medical Certifier Name Title
William Cleaver Attending Physician
Address
100 Park St Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, TOM=11G1C ➢( Glens Falls 5601 562
W OBurial Date Cemetery or Crematory
11/08/2016 Pine View Cemetery
❑Entombment Address
kiii;[ Cremation Queensbury, NY 12804
Date ' Place Removed
gpi Removal and/or Held
:'" aHoldnd/or Address
�=
Cl)
Date Point of
Transportation Shipment
el by Common Destination
iiM Carrier
Ei
0 Disinterment Date Cemetery Address
O Reinterment Date Cemetery Address
pii Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan Funeral Home 01821
Address
11 Algonkin Street Ticonderoga, N Y
iiiI Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
iti
C Permission is hereby granted to dispose of the human remains described above as indicated.
Ni Date Issued 11/07/2016 Registrar of Vital Statistics L J j,
(signature)
iii District Number 5601 Place Glens Falls)1.!y-'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tit Date of Disposition 10116 Place of Disposition �,�() . Cr . ,�,.,
(address)
Ili
CC (section) // (lot numbe (grave number)
Ci �''
Name of Sexton or Person in Charge of Premises 116/j 041ti"
3 (pse print)
Signature � � Title (�-F.M }
(over)
DOH-1555 (02/2004)