Pierce, Mial 411, e . . if cm
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Mial G. Pierce Male
Date of Death Age If Veteran of U.S. Armed Forces,
ii December 7,2017 75 War or Dates
k: Place of Death Hospital, Institution or
: r
City, Town or Village ilton Street Address 521 Middle Line Road
Manner of Death Mural Cause ( Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
gi Medical Certifier Name N\‘Chase k_ as amp atIro pG pirq5'' 1��`` Can
Address + t4 41 RI" SOg`klbkrIS
yaI(S
:'! Death Certificate Filed District Number I i f Register Number 57
City, Town or Village Milton `1- b I
❑Burial Date Cemetery or Crematory
December 8,2017 PineView Crematorium
❑Entombment Address
❑x Cremation Queensbury,NY
Date Place Removed
gRemoval and/or Held
g and/or Address
Hold
0
Date Point of
' " Transportation Shipment
aby Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
�;. Registration Number Permit Issued to
Name of Funeral Home Mason Funeral Home 01117
Address
PO Box 277,Fort Ann, NY, 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
;•:!: Permission is hereby granted to dispose of the huma o : s describe abov as in '
Date Issued 12/08/2017 Registrar of Vital Statisti .,��'
(signature)
;}; District NumberL4 ) ' Place Town of Milton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tz Date of Disposition 12I I In Place of Disposition �,V. .� CM--�s�
a (address)
tli
N
IX (section) (lot number) (grave number)
SName of Sexton or Person in Charge of Premises -CI,I.tr-
LZ (pi ase print)
Signature Title `-40 �i-�`"�
"`"������ (over)
DOH-1555 (02/2004)