Foote, M.D. Joseph 44 Car-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joseph Harrison Benjamin Foote, M.D. Male
Date of Death Age If Veteran of U.S. Armed Forces,
Mi
Dec. 1 9, 201 1 79 yrs. War or Dates no
Place of Death Hospital, Institution or
City, Town or Village Fort Ann Street Address 1 440 County Rte. 1 6
Manner of Death Natural Cause El Accident El Homicide El Suicide 17 Undetermined ri Pending
Circumstances Investigation
tu Medical Certifier Name Title
Mark Hoffman, M.D.
Address
Pruyn Pavil ion, Park st_ Glens Falls, NY. 12.801
giiDeath Certificate Filed District Number Register Number
City, Town or Village Fort Ann 5754 7
giii 0 Burial Date Cemetery or Crematory
Dec. 20, 2011 PineView Crematorium
Entombment Address
[ Cremation Queensbury, NY. 12804
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
F=' Hold
C
Date Point of
ta Transportation Shipment
it by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iiNiiii Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01 1 1 7
Address
18 George St. , Fort Ann, NY. 12827
Nit Name of Funeral Firm Making Disposition or to Whom
441 Remains are Shipped, If Other than Above
• Address
l
pg
1 Permission is hereby granted to dispose of the human rem ns described above a syndicated.
Date Issued 12/1 9/1 1 Registrar of Vital Statistics ,—,fu ` jt/4
(signature)
District Number 5754 Place Town of Fort A' n, NY.
;.;.;' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU• Date of Disposition pa.Z(t Zpq Place of Disposition2 U,N (Zvi-b fill.
(address)
Ili
CO
CC (section) (lot number)- (grave number)
Name of Sexton or Per n in Charge f f Premises elt,st --- J9NH tr-
(please print)
• Signature A--, - Title CaC rim Td(Z
(over)
DOH-1555 (02/2004)