Mayne, Merwin kSY
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Merwin B. Mayne Male
Date of Death Age If Veteran of U.S. Armed Forces,
ai June 2, 19 94 8 8 War or Dates No
4 Place of Death Hospital, Institution or
Z City, Town or Village Town of Glenville Street Address 41 Worden Road
f - Manner of Death Natural Cause 0 Accident El Homicide 0 Suicide El Undetermined Pending
tki Circumstances Investigation
W Medical Certifier Name Title
Alan Levin MD
Address
il 395 Saratoga Road, Glenville, NY 12302
Death Certificate Filed District Number Register Number
City, Town or Village Town of Glenville 4651 83
Date Cemetery or Crematory
0 Burial June 6 , 1994 Pine View Cemetery
Address
❑Cremation Queensbury, NY
Date Place Removed
0❑Removal and/or Held
In
and/or Address
Hold
Q Date Point of
yQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01583
>is Address
26 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
'w" Remains are Shipped, If Other than Above
Address
411
Permission is hereby granted to dispose of the human re ains describe above as indicated.
(� r .
iiiii Date Issued 6/3/94 Registrar of Vital Statistics Z�/t�C,� A.A,{W,01_,./ Deputy
P y
(signature)
District Number 4651 Place Glenville, NY
I certify that the remains of the decedent identified above were disposed of iii accordance with this permit on:
F
W Date of Disposition 6/6/94 Place of Disposition pine View Cemetery Queensbury NY 12804
2 (address)
LW
Ondawa 31-C 2
GIX (section) (lot number) (grave number)
Name of Sexto or Person in Charge of Premises Rodney G. Moshe r
(please print)
W Signature e t+ Title Supt .
DOH-1555 (10/89) p. 1 of 2 VS-61