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McCormack, Patrick J.
12.1.1? NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Patrick J McCormack Male Date of Death Age If Veteran of U.S.Armed Forces, 12/02/2020 67 Years War or Dates �.. Place of Death Hospital,Institution or WCity,Town or Village Corinth Town Street Address 44 Chapman Street,Corinth Town,New York 12822 'p Manner of Death ©Natural Cause Ei Accident ❑Homicide El Suicide 0 Undetermined n Pending U Circumstances Investigation W Medical Certifier Name Title 0 Donald Merrihew MD Address 319 Bay Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Corinth 4553 32 0 Burial Date Cemetery,Crematory or Facility Name 12/04/2020 Pineview Crematory Entombment Address lCremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held H v Hold Address 0 d Date Point of Ul j Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above g Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/03/2020 Registrar of Vital Statistics Brenda L Peris(Electronically Signed) (signature) District Number 4553 Place Corinth, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: � 24,Z Date of Disposition 12 'H�ZO Place of Disposition • �,a,,,�L W (address) W CC N (section) (lot Timber) I (grave number) 4 0 Name of Sexton or Person in Ch of Premises f't� M4t1 Z pleas print/ �}_ '/ W Signature � Title `I �l DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) a, 1 4 2 5 9 Receipt Human remains of delivered on , 20 Pine View Cemetery RRpte es nting the funeral home named on burial permit Official Funeral Directors Reg.or License#