McGovem, Mathew J. flit
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Matthew J McGovern Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/03/2020 22 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Corinth Village Street Address 217 Palmer Avenue 1,Corinth Village, New York 12822
W Mannerof Death Undetermined Pending
W Natural Cause Accident Homicide Suicide g
U Circumstances Investigation
W Medical Certifier Name Title
David DeCelle Coroner
Address
40 McMaster Street,Ballston Spa,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Corinth 4553 7
Burial Date Cemetery,Crematory or Facility Name
02/10/2020 Pineview Crematory
Entombment Address
RI Cremation Queensbury,New York
Donation ?
0 ❑Removal Date Place Removed
and/or and/or Held
~f� Hold Address
O
IL Date Point of
N Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Z Address
w
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/05/2020 Registrar of Vital Statistics Rose E Farr(Electronically Signed)
(signature)
District Number 4553 Place Corinth, 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 Z 10110 Place of Disposition , P�--
W
2 (address)
W
NlZ (section) /!ot number) (grave number)
0 Name of Sexton or Person in Charge of Premises s`+ �
Z /�� lease print
W Signature Title fA
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 013323
Receipt
Human remains of delivered on , 20
Pine View'Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#