Jezewski, John Joseph F 4 -)1
2_NEW YORK STATE DEPARTMENT OF HEALTH L Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Joseph Jezewski Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/19/2022 92 Years War or Dates
▪ Place of Death Hospital,Institution or
W City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death 0 Natural Cause Accident Ej Homicide OSuicide FlUndetermined El Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
O Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 66
ElBurial Date Cemetery,Crematory or Facility Name
09/20/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
CO
0
Date Point of
Cl)DTransportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
5 Address
CZ
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/20/2022 Registrar of Vital Statistics Aimee L Mahoney(Electronically Signed)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF- --'
Z Date of Disposition !I ZI ill Place of Disposition
(L., it_
2 (address)
W
NCC (section) (lot num (grave number)
SName of Sexton or Person in Charge Premises °i L- "..`'tt
Z T (please print)
WJ /u f
Signature
DOH-1555(07/18)p 1 of 2
�. ,€
Public Health Law Sec. 4145(2b)
Receipt
Human remains of '• delivered on - , 20
I
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#