Mach, Joseph NEW YORK STATE DEPARTMENT OF HEALTHAi U.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joseph W. Mach Male
Date of Death Age If Veteran of U.S.Armed Forces,
December 16,2012 84 War or Dates WW II
I... Place of Death Hospital, institution or
Z City, Town or Village Lake George Street Address 27 Olde Coach Road
pManner of Death !Xj Natural Cause 1 1 Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Vuj Medical Certifier Name Title
p Anthony Petracca Jr. MD
Address
3 Iron Gate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village T/O Lake George 5651
❑Burial Date Cemetery or Crematory
Entombment December 18,2012 Pine View Crematory
Address
0 Cremation _21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
O Date Point of
N Transportation Shipment
pp by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i-- Remains are Shipped, if Other than Above
2 Address
• Permission is hereby granted to dispose of the human r ►d?; s described abov indica d.
Date issued 12-18-12 Registrar of Vital Statistics C4 C
(sr nnatu e)
District Number 5651 Place T/O Lake George,NY
I certify that the remains of the decedent identified above were disposed of in accordance with thispermit on:
• Date of Disposition 17,4-.t2 Place of Disposition VM,,a �NwKrltm•.
2 (address)
W
co
(section) (rot number4sit (grave number)
pName of Sexton or Person in Charge of Premises (0
Z ( lease print)
9
W Si nature Title Cit / 1d Q.
(over)
DOH-1555 (02/2004)