Mace, John i -# 3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John J.Mace Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/30/2018 96 Years War or Dates wwll
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
- Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Bain MD
Address
• 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 602
❑Burial Date Cemetery or Crematory
01/03/2019 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
• Address
3809 Main St,Warrensburg,New York 12885
s Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
u
- Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/02/2019 Registrar of Vital Statistics ppbertA Curtis(ECectronicaCCySigned)
(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:
1 Date of Disposition ( /1 (15 Place of Disposition ',, l(ntl d r>.r
" (address)
Y
(section) (lot number (grave number)
• Name of Sexton or Person in Charge of Pr mises /c'� r ] QN^+1t
JA (pl$ase pri /may 1�,`y_• '
ip$ / it frE I1 OC
Signature : � Title
(over)
DOH-1555(02/2004)