Hoffay, Mark NEW YORK STATE DEPARTMENT OF HEALTH 2 3 Vital Records Section Burial - Transit Permit
74 Name First Middle Last Sex
Mark C. Hoffay Male
Date of Death Age If Veteran of U.S. Armed Forces,
r April 21,2013 52 War or Dates
X Place of Death Hospital, Institution or
'Z City, Town or Village Glens Falls,NY Street Address Glens Falls Hospital
• Manner of Death I XI Natural Cause n Accident ❑Homicide n Suicide 1-1 Undetermined Pending
Circumstances Investigation
itt Medical Certifier Name Title
James Hicks,MD
Address
f Main Street,Warrensburg,NY
Death Certificate Filed District Number Re ster Number
,r„2 City, Town or Village Glens Falls,NY 5601 g�-1 1
❑Burial Date Cemetery or Crematory
April 24, 2013 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
• and/or Address
H Hold
N
O Date Point of
NE Transportation Shipment
'p by Common Destination
Carrier
pi Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'*' Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
`' 407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r
l Permission is hereby granted to dispose of the human remains described abo as ' i ated.
Date Issued 0Y/1 Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 14,'ZS'-(3 Place of Disposition +ce to4 �rrmc'Cdfivri-
w (address)
W
CO
re (section) ffj `(lot number) (grave number)
O Name of Sexton or Person 'n Charge of Pre ises !�)fi �
G Z ( lease print)
W ly_ Title (WAIN_Signature
(over)
DOH-1555(02/2004)