Mohoney, Thomas NEW YORK STATE DEPARTMENT OF HEALTH % - ‘ 4 lL Ic
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas John Mahoney Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 21, 2013 69 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause El Accident 0 Homicide 0 Suicide Undetermined ni Pending
Circumstances Investigation
Medical Certifier Name Title
Mark Hoffman, Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls S 6° j } L
❑Burial Date Cemetery or Crematory
July 23, 2013 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
�;❑Transportation Shipment
ti by Common Destination
Carrier
Disinterment Date Cemetery Address
t.
9 Reinterment Date Cemetery Address
Permit Issued to Registration Number
li Name of Funeral Home M. B. Kilmer Funeral Home 01077
tiii Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Y • Address
i
Permission is hereby granted to dispose of the human remains described above as indicated.
1
`7 Registrar of Vital Statistics
Date Issued 3��� LAt)
(signature)
6-7 District Number g jd j Place �S F\Xs i 1" Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/23/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
k (section) ( number) (grave number)
g r` S.9
Name of Sexton or Person i Charge of Pr mises rrsls]�
(please Tint)
Signature Title GTht..
(over)
DOH-1555 (02/2004)