Mahar, Robert NEW YORK STATE DEPARTMENT OF HEALTH
37
Vital Records Section Burial - Transit ermit
Name First Middle Last Sex
ober-� rAi I -£ M ether /�
Date of Death ��L i� +� Age f If VeteranD of tesS. Armed Forces,/
}- P -ce of Death 11 t L
Hospital stitution or
own or Village QL63Z.1�' Fe ks treet Address Q L3-,JS it-ezts
T anner of Death' Natural Cause Accident Homicide 0 Suicide Undetermined Pending
141
0 `�- Circumstances Investigation
to Medical Certifier Name Title�U?A►?Awe_ oercc i n
Address
319 Main t _ 110 rre ;Al i2E85"
th Certificate Filed District Number Register Number
FA C 0-Ie_ns Fed is 01 r6Z
❑Burial Date i.$113Cemetery or rematory D❑Entombment7 / (",e 1)1
Address
1]:iitjitcremation & 0 OR_&YL. 4 0 0 I J S 3l.)YZ1 17
Date Place Removed
Z El Removal and/or Held
4
1.R and/or Address
Hold
CA
0 Date - Point of
Transportation Shipment
. by Common Destination
Carrier
Disinterment Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Ha\'nclyd Aker- rune(cc I N(:gib 01 110
Address
11 La-rave:4-4c S-trcct , Queensbury , Nev,i \i, Ic la soy
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above _ _
2 Address
t
Lu
9' Permission is hereby granted to dispose of the human remains described a'iove as indic6ted.
Date Issued 7 151(.2 Registrar of Vital Statistics W Li )
(signature)
District Number S 6 D / Place 6 (sz,,5 F t, S /4 V
r`
I .', I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z � /
Date of Disposition 1-i %3 Place of Disposition AtVuNd C c fa e ikl...
2 (address)
Ili
to
ilk (section) Plot n mber) (grave number)
C. Name of Sexton or Person in Charge of Premises 1t,'I t 31466
(pl se print)
)11
Signature di/L. Title ((ZEF11 AITAI .
(over)
DOH-1555 (02/2004)
M