McCormack, Mary NEW YORK STATE DEPARTMENT OF HEALTH 4 - lt 4t I I
Vital Records Section Burial - Transit Permit
Name First Middle i 'c.' • Sy
Mary M. c r ,-).-,-,.4(..:)=
m. Date of Death 3 2 2 011 Age 5 3 If Veteran of U.S. Armed Forces, n/a
War or Dates
.Place of Death Hospital, Institution or
2 City, Town or Village South Glens Falls Street Address 129 Hudson S t .
aManner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined 0 Pending
W.
Circumstances Investigation
Medical Certifier Name Title
J . Paston, MD
Address
211 Church St . Saratoga Springs NY
Death Certificate Filed District Number Register Number
City, Town or Village South Glens Falls
[]Burial Date 3 8 2011 Cemetery or Crematory
Pine View Crematory
'`; []Entombment Address
Cremation Quaker Rd , Queensbury NY
Date Place Removed
Removal and/or Held
2 and/or
Address
kr Hold
ID
0 Date Point of
i 0 Transportation Shipment
d by Common Destination
mi Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iiiN Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home IHIV25 01465
Address
94 Saratoga Ave South Glens Falls NY
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
cr.
Lu
Permission is hereby granted to dispose of the human re ains describe bove as indcated.
Date Issued 317 o ►t Registrar of Vital Statistics Z
(signature)
District Number H. S�I`i Place t)/41 Nia, 6 ky25 f/
.,.:„„„
,',;. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3- 9--1i Place of Disposition Pens 014.4 Co%cf o 1 t/14%
(address)
la
VI
C (section) , _ (lot camber) (grave number)
Name of Sexton or P rson in Charg of Premises r.3\ o'". "
j� n � 111 (please print)
iltSignature 1/// Title aAll i
(over)
DOH-1555 (02/2004)