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MUllen, J NEW YORK STATE DEPARTMENT OF HEALTH It t 9 Vital Records Section Burial - Transit Permit Name First Middle Last Sex J. David Mullen Male Date of Death Age If Veteran of U.S. Armed Forces, January 31, 2013 76 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital 13 Manner of Death n Natural Cause 111 Accident n Homicide n Suicide El Undetermined Pending ili Circumstances Investigation UI Medical Certifier Name Title CI Gamal Khalifa, Dr. Address 100 Park Street Glens Falls 12801 Death Certificate Filed District Number— Register Number City, Town or Village Glens Falls `f 7 0 Burial Date Cemetery or Crematory February 1, 2013 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ri Removal and/or Held 0 and/or Address p Hold Date Point of CTransportation Shipment by Common Destination C Carrier Disinterment Date Cemetery Address Reintermentcii Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address ce w -- - o. Permission is hereby granted to dispose of the human remains de c 'be aaple icated. Date Issued ,0//3/120/3 Registrar of Vital Statistics /i,. (signature) District Number ,,(oo/ Place ks,z.„ ,G . Ay I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w W Date of Disposition 02/01/2013 Place of Disposition Quaker Road Queensbury,NY 12804 (address) ILI W (section) _(lot number)S (grave number) O Name of Sexton or Person in Charge f Premises A,I L.-- i"^� Zplease print) W Signature C Title Cek—oia , (over) DOH-1555 (02/2004)