Demarsh, Mark NEW YORK STATE DEPARTMENT OF HEALTH 4/
k Burial - Translit7Permit
Vital Records Sectioniv
Name First Middle Last Sex
MARK A DEMARSH MALE
Date of Death Age If Veteran of U.S.Armed Forces,
;% 05/07/2016 48 War or Dates
tom Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
ry W Manner of Death Natural Undetermined Pending
C ® Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Circumstances ❑ Investigation
W Medical Certifier Name Title
HUSSEIN ASSI MD
Address
43 NEW SCOTLAND AVE ALBANY NY 12208
r4 Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 987
Date Cemetery or Crematory
❑ Burial 05/09/2016 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
O 0 and/or Address
H Hold
t1)
Q Date Point of
a' Transportation Shipment
V) 0 By Common Destination
6; Carrier
❑ Disinterment
Date Cemetery Address
El Reinterment
Cemetery Address
Reinterment
33 Permit Issued To Registration Number
Name of Funeral Home BREWER FH INC 00211
Address
24 CHURCH ST LAKE LUZERNE NY 12846
Name of Funeral Firm Making Disposition or to Whom
r7 Remains are Shipped, If Other than Above
i' Address
ILI
Q. Permission is hereby granted to dispose of the human remains des rt ed above as' dicated.
Date 05/09/2016 Y 2{;ks1 Irccil la.._
Issued Registrar of Vital Statistics (signature)
District Number 101 Place City of Albany, NY
I certify that the remainsof the decedent identified above were disposed of in accordance with this permit on:
Z I
Date of Disposition S Ili /II, Place of Disposition �int Utt,.✓ avwi l'en—
u (address)
LU
N
CC (section) (lot number) (grave number)
0
0 / C.- ,n w'. Name of Sexton or Person in Charge of Premises Nn"Ler `-' /
(please print)
Zy
Signature - Title (►l �rl
(over)
DOH-1555 (02/2004)