Hayes Jr, James t. j if 'l10
NEW YORK STATE DEPARTMENT OF HEALTH p
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Thomas Hayes Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/07/2016 69 years_. War or Dates
f- Place of Death Hospital, Institution or
City, Tdr (X Xli ( Glens Falls Street Address Glens Falls Hospital
10.
Manner of Death Q-Natural Cause El Accident 0 Homicide ElSuicide riUndetermined 0 Pending
lit Circumstances Investigation
tu Medical Certifier Name Title
Eric Pillemer M D
Address
100 Park Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, TXG CXr 26104X Glens Falls 5601 288
giN OBurial Date Cemetery or Crematory
06/08/2016 Pine View Crematorium
>< 0 Entombment Address
.> Gitremation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
..R and/or Address
b: Hold
(l
0 Date Point of
01 Q Transportation Shipment
C! by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Mii Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01078
Address
82 Broadway Fort Edward, N Y 12828
iiiiM Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
te
w
*` Permission is hereby granted to dispose of the human remains described above as indicated.
iffli Date Issued 06/08/2016 Registrar of Vital Statistics ( AJt.,t �p V\),./V-teKr‘
0 "(signature)
District Number 5601 Place Glens Falls y/JV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
III Date of Disposition ((9 A Place of Disposition 2,4
(address)
ill
CC (section) / (lot numb (grave number)
ci Name of Sexton or Person in Charge of PremisesL Rt
(ease print)
: Signature6_ Title ar, n
(over)
DOH-1555 (02/2004)