Loading...
Whitcher, Mark ,/NEW YORK STATE DEPARTMENT OF HEALTH tr . ) it 7 C Vital Records Section Burial - Transit Permit 77 Name First Middle Last Sex , Mark Sheldon Whitcher Male ', :� Date of Death Age If Veteran of U.S. Armed Forces, October 9, 2017 59 War or Dates . Place of Death Hospital, Institution or } City, Town or Village Moreau Street Address al Manner of Death X❑ Natural Cause 0 Accident l i Homicide ❑ Suicide n Undetermined n Pending Circumstances Investigation i Medical Certifier Name Title Michael Adams, Dr. Address 4 10154 Saratoga Raod Fort Edward, NY 12828 Death Certificate Filed District Number Register tuber City, Town or Village Moreau 46-1xD- 0..❑Burial Date Cemetery or Crematory s October 11, 2017 Pine View Crematory ❑Entombment Address ©cremation Quaker Road Queensbury,NY 12804 Date Place Removed nRemoval and/or Held t?z and/or Address Hold t=g Date Point of nTransportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number 4: Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 i,,y Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above -sue Address jLi�:: j Permission is hereby granted to dispose of the human remai escribed v as indicated. • Date Issued 'till/cii17 Registrar of Vital Statistics jetai/ / (signet re) nt District Number cistPa— Place �361 {lo/W5 �(Y `qQ( q1 lug• /. p ) V I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 10/11/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) lit ,1, (section) lot number) (grave number) zt Name of Sexton or Person in Charge of P emises l Svn.44' 4 (please print) Signature EKT Title aat ivi (over) DOH-1555 (02/2004)