Skinner, Corwin NEW YORK STATE DEPARTMENT OF HEALTH b7b
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Corwin G. Skinner Male
Date of Death Age If Veteran of U.S. Armed Forces,
Sept. 09, 2017 fp War or Dates ' 50-' 52
t- Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death fJ Natural Cause Accident [i Homicide Suicide Undetermined ❑Pending
illCircumstances Investigation
la Medical Certifier Name Title
Scott Biaseth MD.
Address
100 Park St_ , Glens Falls DIY_ 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 tom'{ 7
El Burial Date Cemetery or Crematory
❑Entombment Sept_ 1 1 , 201 7 Pi.nPvitaw Crematorium
Address
'iijaCremation Town of Queensbury, NY.
Date Place Removed
Z El Removal and/or Held
an /or Address
Cl)
t;;
Hold
0 Date Point of
Transportation Shipment
Cl by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 Geor St., Pg. Box 277 Fort Ann, NY. 12827
Name of Funerari irm Malting Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
tit
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9/ 1 1 /1 7 Registrar of Vital Statistics tiJ
(signat
District Number 5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
Lu Date of Disposition Man n Place of Disposition -tib OrAVU'0r L.,-
(address)
at
CO
CC (section) (lotber
/1num ) r (grave number)
_. Name of Sexton or Person in Charge of Pre ises C Li. ,.,04-
(please print)
W. Signature (P, Title CWMATIA
1
(over)
DOH-1555 (02/2004)