Kirschen, Mark } v 1 ii z1til
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mark T. Kirschen Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 20,2012 50 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 33 Overlook Drive
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Manner of Death I I Natural Cause ( I Accident Homicide X Suicide [ Undetermined Pending
iii Circumstances Investigation
141, Medical Certified Name Title
Im mL,orpk1 C.-A-6)-yp
i:::' Address
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Death Certificate Filed , V District Numbe5657 R Oster Number
City, Town or Village Queensbury
❑Burial Date Cemetery or Crematory
❑Entombment April 23, 2012 Pine View Crematorium
Address
1 Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
C and/or Address
H Hold
N
0 Date Point of
a.
N Transportation Shipment
p by Common Destination
_ Carrier
Disinterment Date Cemetery Address
(Renterment Date Cemetery Address
ss Permit Issued to Registration Number
'ry.::: Name of Funeral Home Regan & Denny Funeral Home 01443
Address
:a:) 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
k+ Remains are Shipped, If Other than Above
a Address
to
Permission is hereby granted to dispose of the human remains described e as indicated.
4, Date Issued'}IP (&C))a, Registrar of Vital Statistics 4:4--- ` -1
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tuDate of Disposition tjIi6(t1 Place of Disposition ',,,,,UtJ Cw..*{oru.._.
W (address)
N
CC
(section) (tot number) S (grave number)
p Name of Sexton or Person in Charg of Premises r9-v,tr r..1-
Z (please print)
W AL
Signature Title ((LOMA Cott
(over)
DOH-1555(02/2004)