Wormer, Mark Van r *f
NEW YORKSTATE DEPARTMENT OF HEALTH r Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mark Van Wormer Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/26/2020 49 Years ar or Dates
i.., Place of Death Hospital,Institution or
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City,Town or Villagi Glens Street Address 17 Fredella Avenue,Glens Falls,New York 12801
pManner of Death ❑ Natura a I�Accident ❑Homicide Suicide ri Undetermined Pending
0 Circumstances Investigation
W Medical Certifier Name Title
0 Lynn Keil j PA�
Address ,
1340 State Route 9,Lake George Town,New 12845
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 612
ElBurial Date Cemetery,Crematory or Facility Name
01/04/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
/
El Donation
80 Removal Date Place Remove -
and/or and/or Held
NHold Address 4
a Date Point or „.r my
t/) I.1 Transportation
ES Common Shipment
Carrier Destination
El Disinterment
Date Cemetery eddress
-El Reinterment
Date Cemetery Address
4 JIPIP
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 i
1— Remains are Shipped,If Other than Above lille
N Address
CC
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/04/2021 Registrar of Vital Statistics $'v6erty?ndrewCurtir(EYectranicall1Signed)
(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 permit on:
IN
Z Date of Disposition I IS IA Place of Disposition t h. V h
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2 (address)
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toCC (section) Q� (lot number) (grave number)
GName of Sexton or Person in Charge of Premises �' ���
Z (p/ se print)
W Ple-
Signature ‘.9 Title � M�
DOH-1555(o7/t8)p 1 of 2
Public Health Law Sec. 4145(2b) 01 4 3 7 0
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official I Funeral Directors Reg.or License#