Mullen, Patrick NEW YORK STATE DEPARTMENT OF HEALTH 4 ' '' i Op
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patrick M. Mullen Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 23, 2016 64 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward " Street Address 25 Frank Street
4, ::
Manner of Death Natural Cause 0 Accident El Homicide Suicide1-1 Li Undetermined Pending
Circumstances Investigation
SI' Medical Certifier Name Title
David Foote, Dr. `
Address
340 Main St. Hudson Falls, NY 12839
Death Certificate Filed it District Num er Regis Number
City, Town or Village Fort Edward `77,9- .( /�
70 Burial Date Cemetery or Crematory,
September 26,2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Roa I Queensbury,NY 12804
Date Place Removed
Removal and/or Held
Holdor Address
Date Point of
ElTransportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
t Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
'- 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 ma s described abov s indi ted.
Date Issue Al /Leo Registrar of Vital Statistics ,C
(signatu )
District Numbej5 �� � Place cyN p� cJ
- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/26/2016 Place of Disposition Quaker Road Queensbury,NY 12804
• (address)
I ., (section) /A. (lot number)(' (grave number)
• Name of Sexton or Person in Ch ge of Premises at kr StAaic0
(please print)
Signature Z1 Title eh
(over)
DOH-1555 (02/2004)