Mitchell, John NEW YORK STATE DEPARTMENT OF HEALTH ,j,)
Vital Records Section 1' �_, ► Burial - Transit Permit
Name First Middle Last Sex
John Mitchell Male _
Date of Death Age If Veteran of U.S. Armed Forces,
June 16,2013 64 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause n Accident Homicide E Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier
1Name Title
D Michael Miles MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
F City, Town or Village Glens Falls 5601
6
❑Burial Date Cemetery or Crematory
06/18/2013 Pine View Crematory
❑Entombment - Address
CI Cremation Quaker Rd, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
�' Hold
N
O Date Point of
NIJ Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
n 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
15 , Remains are Shipped, If Other than Above
Address
1
11,1
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Ili.711.3 Registrar of Vital Statistics L CAA- P/N-2' L.J
(signature)
a
,; District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w D Date of Disposition (0_ (3 Place of Disposition .7,,,„U4..) (,r` cf actu•-•.
L (address)
W
CO
Ce (section) 4 '' (Ipt number) (grave number)
p Name of Sexton or Perso4e-----
in Charge of Premises C rkf t^ '`-Pt
Z please pent)
Ili
Signature .4 Title r jvlk�Qa
(over)
DOH-1555(02/2004)