Foss, Jason Lawrence 4t gel
NEW YORK STATE DEPARTMENT OF HEALTH ` Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jason Lawrence Foss Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/25/2021 33 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 634 Gansevoort Road, Moreau Town, New York 12803
p Manner of Death ❑ Natural Cause ❑Accident Homicide Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
O David DeCelle Coroner
Address
40 McMaster Street,Ballston Spa,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 51
Burial Date Cemetery,Crematory or Facility Name
10/27/2021 Pine View Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
❑
Cl) Transportation
by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/27/2021 Registrar of Vital Statistics Leeann Mc cabe(Electronically Signed)
(signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZW Date of Disposition /U I1$1 U Place of Disposition •"*.t7/flt(,� ,,.�t—
2 (address)
W
Cl)CC (section) A (lot number) (grave number)
g Name of Sexton or Person in Char Premises / tiv Sks- 4.e
(pleaa print)
W Signature Title ' It �
DOH-1555(07/18)p 1 of 2
1)1
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on _ , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#