Hollenbeck, Joseph NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit rermit
Name First Middle ` �� - Last Sex
4 JOSEPH RICHARD HOLLENBECK MALE
Date of Death Age If Veteran of U.S.Armed Forces,
08/19/2015 76 War or Dates 1957-1959
Place of Death Hospital, Institution
City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
Ilkrt Manner of Death Natural Undetermined Pending
.171 ❑ Accident ❑ Homicide ❑ Suicide ❑ ❑
W.- Cause Circumstances Investigation
Medical Certifier Name Title
rt
— ANDREW DEROO MD
Address
43 NEW SCOTLAND AVE ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1768
Date Cemetery or Crematory
❑ Burial 08/21/2015 PINE VIEW CREMATORY
❑ Entombment Address
®Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
I Hold
Date Point of
a Transportation Shipment
t/)' ❑ By Common Destination
CI Carrier
El Disinterment Date Cemetery Address
0 Date Cemetery Address
Reinterment
Permit Issued To Registration Number
' Name of Funeral Home M.B. KILMER FH 01078
. ) Address
136 MAIN ST S GLENS FALLS NY 12803
Name of Funeral Firm Making Disposition or to Whom
f-` Remains are Shipped, If Other than Above
Address
it
0- Permission is hereby granted to dispose of the human remains described above as indicated.
Date 08/19/2015 Registrar of Vital Statistics 0e-A LS CI_ , 1( t( i
AS
Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit//�� on:
Z Date of Disposition gl WIT Place of Disposition .�t/I.,J i v orv-
L (address)
W
co
CL (section) (lot number) (grave number)
0 �y
31..4
w Name of Sexton or Person in Charge of Premises /
(please print)
Signature Title
(over)
DOH-1555 (02/2004)