Kohn, Paul NEW YORK STATE DEPARTMENT OF HEALTH t Nsd�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Paul Kohn Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 3, 2015 71 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
o Circumstances Investigation
W Medical Certifier Name Title
Noelle Stevens, M.D. Dr.
Address
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls �G U) ,5°
0 Burial Date Cemetery or Crematory
November 6, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
Date Point of
a 0 Transportation Shipment
CAI by Common Destination
G Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
XRemains are Shipped, If Other than Above
Address
a Permission is hereby granted to dispose of the human remains described above as indicated.
R
Date Issued f ) 6 f L5 Registrar of Vital Statistics (,J3 C L -�Q
6
(signatur)
District Number 5 1 Place 6 by s u . 1 S / N y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11/06/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
iii
MI
C (section) (lot number) �- (grave number)
2 Name of Sexton or Person in Charge f Premises (1 t .- S" +
(pl ase print)
Signature A Title ‘
"lLL�
(over)
DOH-1555 (02/2004)