Hover, Jeffrey NEW YORK STATE DEPARTMENT OF HEALTH 0-O
Vital Records Section ,- - Burial - Transit Permit
"
Name First Middle Last Sex
r Jeffrey Allen Hover Male
h Date of Death Age If Veteran of U.S. Armed Forces,
k March 18, 2015 37 War or Dates
f Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 1-1 Undetermined ❑ Pending
.> Circumstances Investigation
Medical Certifier Name Title
Vim; Michael Miles,
M ' Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Nmbr
City, Town or Village Glens Falls ,e,
0 Burial Date Cemetery or Crematory
March 19, 2015 Pine View Crematory
❑Entombment Address
c ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
-fif Date Cemetery Address
'« ❑ Disinterment
❑ Reinterment Date Cemetery Address
374 Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
t Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2 L ! c [1 S Registrar of Vital Statistics (/c� r.,-. ,UJ _.A.."i
(signature)
z.
District Number 5L p / Place 6 (�,_5 F"�, V 1. c d
( �
b I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
;Ile(J:e.,.: C040c.,-nc.for;vM
IiN Date of Disposition 03/19/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in C rge of Premises t in7Cirn7 ( w,2e/tom
��� (please pent
Signature ��- Title
(over)
DOH-1555 (02/2004)