Moll, Mark a•.. ' ✓
NEW YORK STATE DEPARTMENT OF HEALTH I Burial - Transit Permit
Vital Records Section
} Name First Middle Last Sex
Mark John Moll Male
}: Date of Death Age If Veteran of U.S. Armed Forces,
'' ti June 19, 2015 63 War or Dates 191-o— tqi-a,
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 12 Gregwood Circle
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Timothy Murphy
;•:� Address
::f:: 52 Haviland Ave,Glens Falls,NY 12801
:; :; Death Certificate Filed District Number Register Number
_ :: City, Town or Village Queensbury,NY 5601 l 10
❑Burial Date Cemetery or Crematory
❑Entombment June 22, 2015 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
F' Hold
Cl)
O Date Point of
yn Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'� Permit Issued to Registration Number
:j Name of Funeral Home Regan Denny Stafford Funeral Home 01443
rr.' Address
V, 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
...if; Permission is hereby ranted to dispose of the huma remains described a ove as indicated.
i:Z:, Date Issued (pia.), (cRegistrar of Vital Statisticscc�.-_ Q ni,..._
(signature)
, : District Number (oc) Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition C-d.c(_is Place of Disposition 1't'n e U:ew, _re n,w#�-iv,,,�
W (address)
N
O (!ectio (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises i Zv►ndr4-I,y i3r,)n ek
Z /J (please print)
W Signature 2�-�-„//, Title ercma. i-7, ASc4•
(over)
DOH-1555(02/2004)