Hart, James Allen Sr. --- . # gz0
NEWYORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records ✓`
Name First Middle Last Sex
James Men Hart Sr. Mate
Date of Death Age If Veteran of U.S.Armed Forces,
10/08/2022 82 Years Waror Dates 1960-1960
i_ Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 16 Grey Fox Drive,Moreau Town,New York 12828
O Manner of Death El Natural Cause Accident El Homicide Duicide ❑Undetermined ❑Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
O Michael Adams MD
Address
1448 Route 9,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Moreau District Number Register Number
City,down or Village 4562 54
BurialH
Date Cemetery,Crematory or Facility Name
.
10/17/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z• Removal Date Place Removed
and/or and/or Held
- Hold Address
N
0
IL Date Point of
U)❑T ran sportation Shipment
® by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
ElReinterment
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 Otherthan Above
"S Address
CC
LU
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/12/2022 Registrar of Vital Statistics Leeann McCabe(Electronically Signet)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this perrniton: / �
Z Date of Disposition KI1 S 17 L Place of Disposition f—' ---- ` 's___
W adcbess)
2
W
Q (section/ / (lot number/ ` (gm ve rrurnbe�/
0 Name of Sexton or Person in Charge ooff P ernises (p/bseprinr)
W Signature l Title (POM "
.d:
DOH 1555(018)p1of2
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#