Mahr, David R
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iiiIiiiIiii Name First Middle Last Sex
David Mahr male
Date of Death Age If Veteran of U.S. Armed Forces,
07/17/2006 50 War or Dates n/a
}. Place of Death Hospital, Institution or
2t City, T eta i#ls a Glens Falls Street Address Glens Falls Hospital
litiManner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ElUndetermined ❑Pending
ILLI Circumstances Investigation
Ca
tu Medical Certifier Name _. Title
:0 Amy Hogan—Moulton, MD
Address
2 Broad Street Plaza, Glens Falls, NY
Death Certificate Filed District Number Register Number
City, lesitXXIX/DOM Glens Falls 5601
t_tBurial Date Cemetery or Crematory
07/21/2006 Pine View Cemetery
❑Entombment Address
['Cremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
t=` Hold
to
O Date Point of
Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton—Healy Funeral Home 01682
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
• Address
2
Ui
Permission is hereby granted to dispose of the huma remain describ d above as i•dic ted.
iiiT Date Issued?//'9 260- Registrar of Vital Statistics o - rs, ♦ Li21"<—_
(signature)
iiIi District Number L(O dy Place 6/ /j5 //S, ,fit, /aso f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
III Date of Disposition 7/21/06 Place of Disposition PINE VIEW CEMETERY,QUEENSBURY NY
', ► (address)
iiii MOHICAN 91-F 1
ta
III (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises MICHAEL GENIER
,2 9i",",..4A,A, (please print)ttal
Signature Title SUPT.
(over)
DOH-1555 (02/2004)