Hazlett, Donald H Li) 4 Is---
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald H. Hazlett Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/08/2022 88 Years War or Dates
F Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death II Natural Cause Accident ❑Homicide Suicide nUndetermined ri Pending
W U f 'Circumstances Investigation
W Medical Certifier Name Title
CI Scott Biasetti MD
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 610
Burial Date Cemetery,Crematory or Facility Name
12/09/2022 Pine View Crematory
Entombment Address
▪Cremation Queensbury Town,New York
▪Donation
0❑Removal Date Place Removed
- and/or and/or Held
~- Hold Address
N
0
a Date Point of
(I)ETransportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
Address
6357 Nys Rte#30, Indian Lake,New York 12842
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
g Address
CC
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/08/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(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—
WDate
Date of Disposition Iz I I it. Place of Disposition e j r AL _ _
W
CCCC (section) /� (lot number) (grave number)
0 Name of Sexton or Person in Charge P mises '��
Z ( ease print)
Title t �
W Signature ����
DOH-1555(07/18)p 1 of 2
pup . 1,. i 7
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#