Mohan, Dawn M. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dawn M Mohan Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/15/2020 60 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Corinth Town Street Address 54 Holmes Road,Corinth Town,New York 12822
W Manner of Death a Natural Cause Accident ❑ Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
John Mongan DO
Address
3 Care Lane,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Corinth 4553
Burial Date Cemetery,Crematory or Facility Name
05/18/2020 Pineview Crematory
Entombment Address
1 Cremation Corinth Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
l—N Hold Address
O
a Date Point of
to 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
F— Remains are Shipped,If Other than Above
Address
Q
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/16/2020 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
WDate of Disposition �— �j?�j Place of Disposition A}
2 (address)
W
U) /section) (lot number) (grave number)
IX
0 Name of Sexton or Pers 7in C rge f Premises
(please print)
W Signature Title
DOH-1555(07/18)p f0f 2
Public Health Law Sec. 4145(2b) 013842
Receipt
a
Human remains of delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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