Beaudet, Mark V,It * 7 ).s
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section / `
Name First Middle Last Sex
:.: Mark F. Beaudet Male
:r:. Date of Death ..Age If Veteran of U.S. Armed Forces,
September 23, 2015 '~ 51 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death I Xi Natural Cause Accident n Homicide Suicide Undetermined Pending
�f Circumstances Investigation
Medical Certifier Name Title
0. Paul F.Bachmann MD
:K: Address
3767 Main St.Warrensburg,NY 12855
Death Certificate Filed District Numbe ��� Register Numbe
i
Cty, Town or Village Glens Falls, NY J
.. ❑Burial Date Cemetery or Crematory
September 28, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F' Hold
0 Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i•: Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rF'iains described above as Indic. ed.
Date Issued 0? a4 rw)J5 Registrar of Vital Statistics //L _ AID .J`
JJJ I . - signature)
District Number 5 i 1 Place / 'ir:, /4' C:
I certify that the remains of the decedent identified above wer- disposed of in accord.nce with this permit on:
W Date of Disposition I0`7.1g6 Place of Disposition f nt IL/ C 1 Ir$ra�/`
2 (address)
W
CO
0 (section) A__ (lot number)(- (grave number)
Q Name of Sexton or Person in Charge of Premises (4t1 ..IAAIt+
Z (please print)
W Signature s Title 41.Vi PO(
(over)
DOH-1555(02/2004)