Paige, Hollis H tie' ' '' m
NEWYORKSTATEDEPARTMENTOFHEALTH ` ';„,.. ` ,�
Bureau of Vital Records �— �' Burial - Transit Permit
Name First Middle Last Sex
Paige r. Male
ftfDth Age If Veteran of U.S.Armed Forces,
01/22/2023 k 81 Years War or Dates 1959-1962
Place of Death Hospital,Institution or
5 City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause Accident Homicide ESuicide EUndetermined ❑Pending
AU
§ 'rtifier Circumstances Investigation
Name Title
Aaron Heckler PA
Address ��
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
_y,Town or Village 1 5601 42
Burial Date Cemetery,Crematory or Facility Name
,
01/23/2023 Pineview Crematorium
Entombment Address
IJCremation Queensbury Town,New York `moo.
s;EiDonation
Z Date Place Removed
0❑Removal
i,; and/or and/or Held
Hold Address
pi
trt#0Transportation
Date Point of
t' by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
IH Remains are Shipped,If Other than Above
S Address
tC
tiff
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/23/2023 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature/
District Numak 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:
Z .-->
Date of Disposit IZH Z3 Place of Disposition ��11-- '
Z (address)
W
(section) (lotnumber/ (grave number)
Name of Sexton or Person in Charge of P e ises / A 4.,,— ��
(else print)
Signature Title 11 C fr(�1on`(C7a
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemeter Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ,