Mumblow III, George it
NEW YORK STATE DEPARTMENT OF HEALTH S ��
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George Andy Mumblow III Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/25/2011 50 years War or Dates
#- Place of Death Hospital, Institution or
2 City, Tow ll Street Address Glens Falls Hospital
• Manner ofD XX Glens Falls
eath K4 Natural Cause [l Accident El Homicide Ej Suicide El Undetermined r i Pending
W Circumstances Investigation
W Medical Certifier Name Title
Joseph C Mihinda M D
Address
20 Murray Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TownAgitrxVIIIMXX CIPns Falls 5601 466
DBurial Date Cemetery or Crematory
['Entombment Pine View Cemetery
Address
rgCvmation Queensbury. NY 12804
Date Place Removed
Z Removal and/or Held
2and/or❑ Address
N Hold
O Date Point of
CL
Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Ul
Permission is hereby granted to dispose of the human remains described a ov as i c ted.
Date Issued 10/27/2011 Registrar of Vital Statistics C.J _
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
U Car• Date of Disposition mill II( Place of Disposition ttit rem fartutu,
(address)
Ui
0
le (section) lot number (grave number)
0
Name of Sexton or Pers in Charge of 'remises L ht'*$fi r tMNFE-
::.i (please print)
44
Signature Title RC C i'n Mae,
(over)
DOH-1555 (02/2004)