Mitchell,Dennis Roger t(03
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dennis Roger Mitchell Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/27/2020 70 Years War or Dates 1969-1975
II.— Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death 0 Natural Cause 1:1Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
Melody Long PA
Address
100 Park Street,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 50
❑Burial Date Cemetery,Crematory or Facility Name
01/30/2020 Pine View Crematory
Entombment Address
JC Cremation Queensbury Town, New York
Donation
OZ Removal Date Place Removed
and/or and/or Held
F-
N Hold Address
n. Date Point of
N Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
17 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F.. Remains are Shipped,If Other than Above
Address
IX
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/30/2020 Registrar of Vital Statistics Wpdert/gndrew Curtis(EYectronicadySyneq)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition 131110 Place of Disposition w, 1-1 lr —
ui (address)
W
N (section) //ot umber (grave number)
a Name of Sexton or Person in Charge of Premises t`'
(p ase print/Z
W Signature Title
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 2,-19 8 j
Receipt
Human remains of `' _ delivered on , 20
i
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#4"
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