Hogan, John Jay .lZ3Z
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Jay Hogan Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/10/2022 70 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
IJJ
p Manner of Death 11 Natural Cause Accident Homicide []Suicide []Undetermined ❑Pending
C. I (Circumstances Investigation
W) Medical Certifier Name Title
0 Julian Marynczak PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 158
Burial__..R
Date Cemetery,Crematory or Facility Name
03/14/2022 Pine View Crematory
Entombment Address
IICremation Queensbury Town,New York
EiDonation
OZ[]Removal Date Place Removed
and/or and/or Held
0 Hold Address
0
CI- Date Point of
(A[]Transportation
p by Common Shipment
Carrier Destination
[]Disinterment
Date Cemetery Address
C Reinterment
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
H Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/14/2022 Registrar of Vital Statistics 9Kegan Not-in(ECectronicaCCySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 31)4 i ZZ Place of Disposition ��
Ili
2 (ad ress)
W
NCC (section) A(lot number) (grave number)
0
Name of Sexton or Person in Charge of ises ir'� Swath 1
Z (plea print)
tL Signature ` Title fizi'Al Ft Ail
DOH-1555(07/18)p 1 of 2
�'t_ 3 a1
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# '
1 r►` '