Mann, Mary `y L.,fl 1
NEW YORK STATE DEPARTMENT OF HEALTH `
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
,, , Mary Pamela Mann Female
Date of Death Age I If Veteran of U.S. Armed Forces,
03/09/2017 71 War or Dates
M~ry Place of Death Hospital, Institution or
E k City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑ Accident ❑Homicide E Suicide ❑ Undetermined ❑ Pending
=5 Circumstances Investigation
w' Medical Certifier Name Title
mod;' William Cleaver,
Address
Ai
.sue;
100 Park St. Glens Falls, NY 12801
tt Death Certificate Filed District Number i Register Number
x City, Town or Village . Z
k� Date c_
- � 0 Burial Cemetery or Crematory
3 `= 03/10/2017
❑Entombment Address
®Cremation
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
i❑Transportation Shipment
•i by Common Destination
) Carrier
4� ❑ Disinterment Date Cemetery Address
:-❑ Reinterment Date Cemetery Address
;, = Permit Issued to Registration Number
s Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
`"< 9 Pine St/P.O. Box 455 Chestertown NY 12817
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 human remains described above as indicated.
Date Issued 3 f t Q /i ? Registrar of Vital Statistics (.A)C.L&p- 2. '- 6--Ki
(signature)
District Number Ij j I Place (0M.s RU 1 J-s Airy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3114 10 Place of Disposition ef?At 0;, ( gfo6',v,..
(address)
(section) 1(ot number) (grave number)
Name of Sexton or Person in Charge Premises l�1 as r �a•N l
(ptee
print)
Signature Title 11-
f 1611
(over)
DOH-1555(02/2004)