Gollhofer, Jr. Paul NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Paul J.Gollhofer Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/20/2018 81 Years War or Dates Korea
Place of Death Hospital, Institution or
tll City, Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
Manner of Death EkiNatural Cause ❑Accident ElHomicide ElSuicide El
Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
14 Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 121
-['Burial Date Cemetery or Crematory
08/29/2018 Pine View Crematory
Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal
and/or Held
and/or Address
tx
Hold
QDate Point of
.❑Transportation Shipment
by Common Destination
Carrier _
LI Date Cemetery Address
❑Disinterment
Reinterment Date Cemetery Address
ki
Permit Issued to Registration Number
6 Name of Funeral Home Alexander Baker Funeral Home 00037
t ° Address
3809 Main St,Warrensburg,New York 12885
4B Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/27/2018 Registrar of Vital Statistics Caroline:X'Bar6er(ECectronicallySigned)
(signature)
'' District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition $►3b II$ Place of Disposition cMV,,, � a�
(address)
Imo,
(section) (lot nw ber) (grave number)
pName of Sexton or Person in Charge of Premises l �r. pk 9',40
z / (please print)
111
Signature '�Jti•T- Title OF-4)1.1 rait-
(over)
DOH-1555 (02/2004)