Batchelder, Malcolm NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Iii Malcolm A. Batchelder Male
ilei Date of Death Age If Veteran of U.S. Armed Forces,
:.._ Mai t-6, 2014 91 yrs war or Dates no
r Place o Death Hospital, Institution or
City, Town or Village Queensbury Street Address 36 Clements Rd.
1 Manner of Death❑Natural Cause ❑Accident ❑Homicide ®Suicide ❑ Undetermined ri❑Pending
Circumstances Investigation
8 Medical Certifier Name Title
I1 Gary Scidmore PA—C Coroner
Address
6930 State Rte. 8, Brant Lake, NY. 12815
Death Certificate Filed Zi�ct Number egister Number
pi) City, Town or Village Queensbury ( 1
Date Cemetery or Crematory
❑Burial May 27, 2014 PineView Crematorium
Address
::iiii Cremation Queensbury, NY. 12804
Date Place Removed
2❑Removal and/or Held
••.• and/or Address
Hold
0 Date - Point of
N❑Transportation Shipment
fl by Common Destination
Carrier
❑Disinterment Date- Cemetery Address
❑Reinterment Date Cemetery Address
niiiiPermit Issued to Mason Funeral Home Rieaistration Number
Name of Funeral Home
Address
iiiiiiiiiii 18 George St. , PO. Box 277, Fort Ann, NY. 12827
iiiiiiiiiii Name of Funeral Firm Making Disposition or to Whom
it Remains are Shipped, If Other than Above
Address
IZ
iii
iliiii Permission is hereby granted to dispose of the human rem 'ns described 4b ve as indicated.
PI
' � C �--�„Date Issued May 27, 20114egistrar of Vital Statistics � 1
(signature)
iliiiV District Number yc ) Place Town of Queensbury, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
5 Date of Disposition 51701 Place of Disposition �� ( on ..,.
(address)
LU
U
CC (section) tieti—...)tiNti
lot nu ber) (grave number)
AName of Sexton or Pe son in Charge of Premises
g (please print)
!. Signature ryl1� Title C2(v"Itx�
° (over)
DOH-1555 (9/98)