Mallaney Jr., Ross Nicholas NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ross Nicholas Mallaney Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/21/2021 41 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Hudson Falls Village Street Address 3 Forest Street,Hudson Falls Village, New York 12839
p Manner of Death ❑Natural Cause 0 Accident 0 Homicide ❑X Suicide Ei Undetermined 0 Pending
W Circumstances Investigation
V IllMedical Certifier Name Title
p John Aiken Coroner
Address
40 Burquist Road,Fort Ann Town,New York 12827
Death Certificate Filed District Number Register Number
City,Town or Village Hudson Falls Village 5726 19
Burial Date Cemetery,Crematory or Facility Name
07/23/2021 Pne View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
Date Place Removed
ZOLiRemoval and/or Held
— and/or
Hold Address
0
Date Point of
Cl) Li Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
0 Disinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
—. Remains are Shipped,If Other than Above
5 Address
CC
W
G. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/23/2021 Registrar of Vital Statistics Cynthia/7 Bardin(E/ctronicalySignerl9
(signature)
District Number 5726 Place Hudson Falls Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H n
W Date of Disposition 7—c3�?-�► Place of Disposition �l jn(, Yi c�, CcG'�Cy
1 (address)
W
CC (section) (lot number) (grave number)
CC
0
• Name of Sexton or Person in Charge of Premises �I e.!'r�-tiY S2'l r�S
(please print)
W Signature .1,4 /. Title ,rvtfri-dor
DOH-1555(o7/18)p i of 2
Public Health Law Sec. 4145(2b) 0 1 4C
Receipt
1
1 Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#