Mulvany, Dominick '"-
t , ,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
;, Name First Middle Last Sex
kit Dominick Mulvany Male
144 Date of Death Age If Veteran of U.S.Armed Forces,
04/07/2018 82 Years War or Dates
_OatPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Ei Accident 0 Homicide 0 Suicide ri Undetermined ri Pending
Irr
Circumstances Investigation
_ Medical Certifier Name Title
Suzanne Blood MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 175
[]Burial Date Cemetery or Crematory
04/10/2018 Pine View Crematory
âť‘Entombment Address
rfi®Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Date CemeteryAddress
0 DisintermentIA
El Reinterment Date Cemetery Address
ter
Permit Issued to Registration Number
Li Name of Funeral Home Regan Denny Stafford Funeral Home 01443
rg Address
53 Quaker Rd,Queensbury,New York 12804
at Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/09/2018 Registrar of Vital Statistics p6ertA Curtis(ECectronicaCCy signed)
(signature)
, District Number Place
5601 Glens Falls, New York
r,. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LTC Date of Disposition r/t/ig Place of Disposition p h Qti;NA,1 674;14. fltril
y
(section) (lo number) (grave number)
Name of Sexton or . rso in`Charge of Premises U L/r c..,it CD 4104 4-e%e
(please print)
Signature Title C re. -r2 4./
v (over)
DOH-1555 (02/2004)