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Mulcahy, Douglas NEW YORK STATE DEPARTMENT OF HEALTH - Vital Records Section Burial - Transit Permit Name First Middle Last Sex Douglas Robert Mulcahy Male Date of Death Age If Veteran of U.S. Armed Forces, 08/01/2017 60 Years War or Dates I- Place of Death Hospital, Institution or CitLti. y, Town or Village Glens Falls Street Address Glens Falls Hospital O Manner of Death©Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation Medical Certifier Name Title ta Abigail Macomber PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 413 ❑Burial Date Cemetery or Crematory 08/04/2017 Pineview Crematorium ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed Z❑Removal and/or Held and/or Address CO▪ Hold Date Point of • Q TCa ransportation Shipment C by Common Destination Carrier A Date Cemetery Address ❑Disinterment ❑Reinterment Date Cemetery Address vif Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 , Address ": 68 Main Stpo Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom II- Remains are Shipped, If Other than Above • Address O W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/02/2017 Registrar of Vital Statistics 4jgbertACurtis ECectronicallySigned" (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: W f �y Date of Disposition � �l !7 Place of Disposition /�r�eVl�.�,1 �, "r�`'' / (address) W U it (section) `` / (lot number)/ (grave number) aName of Sexton ./'/-r in Char e of Premises .31.1,4'444 [� �2 41cf.-C -e Z / (please print) • Signature Title alor / (over) DOH-1555 (02/2004)