Mock, Gary Thomas NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gary Thomas Mock Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/04/2020 77 Years War or Dates
�.. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 103 Third Street,Glens Falls,New York 12801
IJJ
p Manner of Death ❑X Natural Cause ❑Accident 1=I Homicide 1:1Suicide Undetermined Pending
W U Circumstances Investigation
W Medical Certifier Name Title
G Gerard Abess MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 496
ElBurial Date Cemetery,Crematory or Facility Name
11/05/2020 Pine View Crematory
ElEntombment Address
0 Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
- Hold Address
0
C. Date Point of
co ❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
Q
W
G" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/05/2020 Registrar of Vital Statistics 9'P6ert,InirewCurttrgkctronical6,50ed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this perm'
ll—
Z Date of Disposition 40 Place of Disposition kA,
2 (address)
W
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises t') L S�'^^jd 1�
Z (pie a print)
W Signature Title 011"
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0141 /
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#