Hoag, Robert "11
NEW YORK STATE DEPARTMENT OF HEALTH r • 0 4
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert E. Hoag Male
• Date of Death Age If Veteran of U.S. Armed Forces,
December 16, 2012 78 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident D Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
Dean Reali, Dr.
Address
Park Street Glens Falls, NY 12801
Death Certificate Filed District Numb .
-' Register Number
' City, Town or Village l(r�� '')
0 Burial Date Cemetery or Crematory
December 20, 2012 Pine View
0 Entombment Address
In
1uacer Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held Pine View
and/or Address
All Hold Quaker Road Queensbury,NY 12804
�4 Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
t'
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
fiti Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
,°'' Remains are Shipped, If Other than Above
Address
I
R• Permission is hereby ranted to dispose of the human remains des 'bed bo s 'L -ted.
Date Issued /a /b, 2,9/2— Registrar of Vital Statistics � '
/ (signature)
District Number j(o Q/ Place op/Pis,0 , l/ /07.
• certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/20/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
1
(section) , (lot number) (grave number)
' Name of Sexton or Person in Charge of remises G h nY4 t„...
please print)
t!e' Signature Title
cQ t
(over)
DOH-1555 (02/2004)