Stark, Mary If
NEW YORK STATE DEPARTMENT OF HEALTH' % �16-
Vital Records Section Burial - Transit Permit
im Name First Middle Last Sex
Mary *;. Stark Female
Date of Death Age If Veteran of U.S. Armed Forces,
Nov. 18, 2014 55 yrs. War or Dates no
F Place of 1•.th Hospital, Institution or
r+Z City own) Village Fort Ann Street Address 371 Sly Pond Rd.
Mann- o Death C Natural Cause El Accident El Homicide El Suicide Undetermined Pending
Circumstances Investigation
N Medical Certifier Name Title
.in Max Crossman MD.
Address
poultney St., Whitehall, NY. 12887
<= Deat icate Filed r. M � District Numb Registor Number
Cit Town 'r Village /- j A)AJ '
__
Date Cemetery or Crematory
❑Burial Nov. 19, 2014 PineView Crematorium
Address
®Cremation Queensbury, NY. 12804
Date Place Removed
fl❑Removal and/or Held
r- and/or Hold Address
CO
Q Date Point of
laQ Transportation Shipment
G by Common Destination
Carrier
El
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 0111 7
Address
18 George St. , P.O. Box 277, Fort Ann, NY. 12827
'''= Name of Funeral Firm Making Disposition or to Whom
it Remains are Shipped, If Other than Above
LO Address
laii
4
Permission is hereby granted to dispose of the human remainsre described abo indicated.
'' Date Issued •
Nov. -1 9, 201 trar of Vital Statistics .,/./, ,Q,
iiiii (sign Pure)
Ni District Number 4 '.91 Place < &-)7 't . iZr- /9f02'7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
1.6Date of Disposition i)17af 11 Place of Disposition „ ;,,_, a ,..,
2 (address)
iLi
QCC (section) 9 (tot nurjber (grave number)
Name of Sexton or Perso in Char of Premises ; ,n l
zZ / (please print)
W Signature Title OVA y to 40,
DOH-1555 (10/89) p. 1 of 2 VS-61