Williams, Mark NEI7YORK STATE DEPARTMENT OF HEALTH
t- Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mark Allen Williams Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 8, 2016 60 War or Dates %q 7(o-I t17o
ZPlace of Death Hospital, Institution or
1 City, Town or Village Street Address
Ws Manner of Death ❑Natural Cause ❑ Accident ❑ Homicide u Suicide ❑ Undetermined rli Pending
U Circumstances Investigation
W Medical Certifier Name Title
In Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number, Register Number
City, Town or Village 7 d G S
i1 Burial Date Cemetery or Crematory
February 12, 2016 Pine View Cemetery
❑Entombment Address
0 Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold Pine View Cemetery
N Date Point of
a ❑Transportation Shipment
CO by Common Destination
3 Carrier
Disinterment Date Cemetery Address
riReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
MAddress
W,
C' Permission is hereby granted to dispose of the human remains descr'bed above as indicated.
Date Issued -/O - , 0/(O Registrar of Vital Statistics _...._ C.k.J-Qcif 1 ',-..-1.„
(signature)
District Number 524(0 Place \J.� �j�. \f:, ,a ,.' 15-e=
ti
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 02/12/2016 Place of Disposition Quaker Rd. Queensbury,NY 12804
M (address)
W Next to parents 29B - New Kenesaw 3
CO (section) (lot number) (grave number)
a; Name of Sexton or Person in Charge of Premises Connie L. Goedert
z ,�y (please print)
W Signature ' ` : -‘'G�C--k--C Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)