Novotny, Mark NEW YORK STATE DEPARTMENT OF H O
Vital Records Section Burial - Transit Per it
Name First Middl Last Sex
rTive
r Mark A. Novotny Male
---1v, Date of Death If Veteran of U.S. Armed Forces,
November , 018 54 War or Dates
Place of Dea Hospital, Institution or
City, Town Village Hudson Falls Street Address 1 Dalton Avenue
W Manner of Death X Natural Cause ❑ Accident Homicide Suicide 0 Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Cheryl Morris, NP
lirc
L. Address
Fort Edward Hudson Headwaters Fort Edward, NY 12828
t_: Death Certificate � District Number Register Number
City, Town or Village }----tA.A S m F-,4-cts 5726 a 3
❑Burial Date Cemetery or Crematory
November 6, 2018 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Removal Date Place Removed
z and/or Held
;Q and/or Address
Hold
Date Point of
iEl Transportation Shipment
by Common Destination
1 Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
N• ame of Funeral Home Carleton Funeral Home, Inc. 00281
A• ddress
'' Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
; A• ddress
ir
P• ermission is hereby granted to dispose of the human remains described above as indicated.
Ati
Date Issued /// G M Registrar of Vital Statistics e9.n.t t t.c /< ar c_.4r,
(signature)
District Number 5726 Place f/; 7/i._JJ it
/�U j-e7i ti-re�,
�fi
r. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uf Date of Disposition 11/06/2018 Place of Disposition Quaker Road Queensbury,NY 12804
2: (address)
g
co
E (section) v (lot num r) (grave number)
a` Name of Sexton or Person in Charge of Premises 1O' . 10
Z4 (phase print)
W Signature A-' Title 1404 AA-
(over)
DOH-1555 (02/2004)