Hart, Joseph l /$
NEW YORK STATE DEPARTMENT OF HEt.TH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joseph A. Hart Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 28, 2015 70 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 283 Lamplighter Acres
Manner of Death X❑ Natural Cause Accident ❑ Homicide ID Suicide ❑ Undetermined Pending
Circumstances Investigation
aMedical Certifier Name Title
AgeelA. Gillani, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801 ee��
Pi Death Certificate Filed Districtt w0 Regist r, umber
alb City, Town or Village Moreau
-0 Burial Date Cemetery or Crematory
September 30, 2015 Pine View Crematory
❑Entombment® Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/orHold Address
0 Date Point of
AEl Transportation Shipment
by Common Destination
0 Carrier
IIIDisinterment 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
Remains are Shipped, If Other than Above
Address
W
Eta Permission is hereby granted to dispose of the human re escribe .1.o e as indicated.
Date Issue / 420/J Registrar of Vital Statistics .fil f' n
�n a (si nature) ,� / /er
District Number Place (� 01 /We/re?Ct :J``1 /f {X4 Hs r- 4itL(
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/30/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
a (section) A (lot number)' (grave number)
Name of Sexton or Person in Charge of Premises `1�rs l.- -�eN
ivat
/� (lease print)
9
Si nature Cti Title "YI`O/C
(over)
DOH-1555 (02/2004)