Hohman, Frank NEW YORK STATE DEPARTMENT OF HEALTH ftv 5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Frank J. Hohman Male
Date of Death Age If Veteran of U.S. Armed Forces,
NOv. 07, 2015 71 yrs. War or Dates
h- Place of Death Hospital, Institution or
Z 11� City, Town or Village Glens Falls Street Address Glens Fall s Rolfi to 1
WManner of Death 10Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
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Death Certificate Filed District Number / Register Number
City, Town or Village Glens Falls 5601 5 3-7
❑Burial Date Cemetery or Crematory
Nov. 09 2015 PineView Crematorium
D.i ['Entombment Address
Cremation Queensbury, NY. 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
Lt Hold
0 Date Point of
cL to Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St. , PO. Box 277, Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
bi. Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 1 /0 9/1 5 Registrar of Vital Statistics Ukh,`�,.� q— �/ :1'
v/ v (sign ture)
District Number 5601 Place City of Glens Falls, NY.
" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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ILL Date of Disposition 11/'f (�,,,
/Ic Place of Disposition ,� , �t.„,ti6f,,-
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cc (section) /� (lot number) (grave number)
CI Name of Sexton or Person in Char a of Premises C�� r - �N
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Signature 4 Title 41.644Pft
(over)
DOH-1555 (02/2004)