Hewitt, John NEW YORK STATE DEPARTMENT OF HEALTH, _., ; Burial - Transit j 310 ermit
Vital Records Section
Name First Middle Last Sex
John Hewitt Male
Date of Death Age If Veteran of U.S.Armed Forces,
,, May 10, 2015 88 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death a Natural Cause ❑Accident n Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Matthew Varughese, M.D. Dr.
Q Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number �-,�^ 1 Register Number
City,Town or Village Glens Falls �J (950
❑Burial Date Cemetery or Crematory
05/19/2015 Pineview Crematorium
❑Entombment Address
a ❑X Cremation Queensbury, New York Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
I' Hold
0 Date Point of
0 ❑Transportation Shipment
a. by Common Destination
Carrier
Date Cemetery Address
6 ❑Disinterment
El Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
I- Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
CC
W Address
O.
Permission is hereby granted to dispose of the human remains describ d above ind.
5b Date Issued 0, ofi Registrar of Vital Statistics ,� e
signat e)
District Number 5k/ Place Glens Falls,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition f/LC Ii S Place of Disposition Pineview Crematorium
(address)
W
lA
It (section) lotrnumber) (grave number)
O Name of Sexton or Person in Charge of Premises A„ ,1J/1-
Z (ple se print)L,
W e:,Signature Title OFniigNI,
(over)
DOH-1555 (02/2004)