Mulcahy, Timothy NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Timothy Joseph Mulcahy Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 10, 2012 45 War or Dates
Place of Death Hospital, Institution or
ai it Town or Village Glens Falls Street Address 20 Montcalm Street
C1�IClranner of Death Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
U'+
W, Medical Certifier Name Title
13 Paul Bachman, M.D.
Address
3767 Main Street Warrensburg, NY 12885
,10--th Certificate Filed District Number Register Number
Town or Village 6/ey c f //5 36W LC/
❑Burial Date Cemetery or Crematory
November 16, 2012 Pine View Crematorium
❑Entombment Address
®Cremation I Quaker Road Cueensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F. Hold
6 Date Point of
a. ❑Transportation Shipment
O by Common Destination
13 Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
g Address
Ce
LJ
Permission is hereby granted to dispose of the human remains des r be ab e • Aicated.
Date Issued ////3`zo/2- Registrar of Vital Statistics �2A
/ (signature)
District Number 56Q/ Place o./ev,,. /,q`A /U,y la( 0(
• I certify that the remains of the decedent identified above were disposed of in accordance�with this permit on:
W Date of Disposition III to h i Place of Disposition ,��,,.�� � C �J f,�.,
2 (address)
W
co (section) A (lot number) c (grave number)
g Name of Sexton or Person in Char a of Premises
�' Y t`M''�
z (please print)
W Signature 7 '-m Title me ARid,
(over)
DOH-1555 (02/2004)