Hansen, Steven NEW YORK STATE DEPARTMENT OF HEALTH 4-1
Vital Records Section Burial - Transit Permit
` Name First Middle Last Sex
Steven Dale Hansen Male
W Date of Death Age If Veteran of U.S. Armed Forces,
-- December 24, 2013 59 War or Dates
Place of Death Hospital, Institution or
$P City, Town or Village Glens Falls Street Address House of Grace
Manner of Death El Natural Cause El Accident Ei Homicide n Suicide Undetermined 1---I Pending
CircumstancesInvestigation
dye Medical Certifier Name Title
Mark Hoffman, Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number,
City, Town or Village Glens Falls cj 60 1 J fj 6
❑Burial Date Cemetery or Crematory
December 27, 2013 Pine View Crematory
1,4;❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
,,El Removal and/or Held
and/or Address
e Hold
wet Date Point of
❑Transportation Shipment
by Common Destination
'w-A' Carrier
c Disinterment
Date Cemetery Address
Reinterment iS
Eta
Date Cemetery Address
A*ElPermit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
. ' Address
°' 82 Broadway, Fort Edward NY 12828
°: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Iv
r' Date Issued / 2/ 2 7//3 Registrar of Vital Statistics )c&. ) r\Q `'�
t--- ,g (signature)
District Number 5 be 1 Place 6 � S t-cc ( S / Iv Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
{ Date of Disposition 12/27/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) �lot number) (grave number)
Name of Sexton or Person in harge of Pr raises .+
L S.,
(ple se print)
Signature Title C'C, riot
9
(over)
DOH-1555 (02/2004)