Cogan, Robert Kevin j " ` # Z3
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert Kevin Cogan Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/03/2023 68 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village South Glens Falls Village Street Address 27 Wilson Avenue,South Glens Falls Village,New York 12803
W Manner of Death g
C �Natural Cause Accident �Homicide nSuicide Undetermined nPendin
W
U Circumstances II ''Investigation
W Medical Certifier Name Title
CI Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Village Of South Glens Falls District Number Register Number
City,Town or Village 4524 1
0Burial Date Cemetery,Crematory or Facility Name
01/05/2023 Pine View Crematory
IllEntombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
0
a Date Point of
t)❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
❑Reinterment
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
l— 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 01/05/2023 Registrar of Vital Statistics Samantha Berg(Electronically Signed)
(signature/
District Number 4524 Place Village Of South Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:I—
W Date of Disposition /_7—ZpZ 3 Place of Disposition pf :}o O., ) Cr -,ii,+4.t r{
(address)
1
111
CC (section) (lot number) (grave number)
0 0 JJ.
Name of Sexton or Person in Charge of Premises en 7 @�� Jic
Z (please print)
W Signature Title 00,--4.4i
DOH-1555(o7/18)p 1 of 2
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#