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Hart, Jonathan Todd NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jonathan Todd Hart Male Date of Death Age If Veteran of U.S.Armed Forces, 11/07/2021 48 Years War or Dates Place of Death Hospital.Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death ©Natural Cause Accident Homicide El Suicide Undetermined Pending W Circumstances Investigation 0 Medical Certifier Name Title Suzanne Bergin DO Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 496 0 Burial Date Cemetery,Crematory or Facility Name 11/09/2021 Pine View Crematorium 0 Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held N Hold Address 0 Va?❑Transportation Date Point of p by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom .— Remains are Shipped,If Other than Above a Address W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/08/2021 Registrar of Vital Statistics Rp6ert Andrew Curtis(E(ectronicafySigned) /signature/ District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition /j/1p)14 Place of Disposition 477 . 1---- 2 (a dress/ W CO (section) (lot number) (gram number) Name of Sexton or Person in Charge of Premised IAI % LZ (pose print) W Signature g Title I //wlk. DOH-1555 io7/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt % 1! Human remains of I ' delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License#