Kolar, Brien NEW YORK STATE DEPARTMENT OF HEALTH # VS-
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Brien Patrick Kolar Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 4, 2014 61 War or Dates
• .- Place of Death i Hospital, Institution or
, ,, City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
? Medical Certifier Name Title
Gamal Khalifa, Dr.
Address
} 100 Park Street Glens Falls 12801
'l. Death Certificate Filed District Number Regist Number
• City, Town or Village Glens Falls
11 \ 1
❑Burial Date Cemetery or Crematory
July 7, 2014 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
°f Date Place Removed
❑ Removal
and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address Li Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
4: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r Permission is hereby grant to dispose of the human re ins des ibed abo e as indicate .
Date Issued Registrar of Vital Statistics dC.Q c� ,!� / ° ,/ G u \
(Signature)
��District Number 6 Place � �� `itzii
ii
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
_ . Date of Disposition 07/07/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
I (section) (lot number) (grave number)
L' Name of Sexton or Pers in Charge of Premises ii&please print)
' Signature � Title 01
9 A
(over)
DOH-1555 (02/2004)