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Horstmyer, Mark A
(y111 NEW YORK STATE DEPARTMENT OF HEALTH w Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mark A. Horstmyer Male Date of Death Age If Veteran of U.S.Armed Forces, 08/19/2021 68 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Hadley Town Street Address 211 B Stony Creek Road, Hadley Town, New York 12835 W Manner of Death Undetermined Pending W © Natural Cause Accident Homicide ❑Suicide Circumstances Investigation W Medical Certifier Name Title CI Suzanne Bergin DO Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Hadley 4558 17 ▪Burial Date Cemetery,Crematory or Facility Name 08/21/2021 Pine View Crematory EDEntombment Address ElCremation Queensbury Town, New York ▪Donation ElRemoval Date Place Removed and/or and/or Held H Hold Address 0 O. Date Point of U) 1-1 Transportation p by Common Shipment Carrier Destination Date Cemetery Address Disinterment Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above g Address CC a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/21/2021 Registrar of Vital Statistics Pauline G Smead(Electronically Signed) (signature) District Number 4558 Place Hadley, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H / Z Date of Disposition 6^�3'ZOl/ Place of Disposition j �h[ U1'CJ t .ce.vru_1orf ILI 2 (address) W N (section) (lot number) (grave number) Name of Sexton or Pe on i h rge of Premises t A"r1 Gam /-t. (please print) Z 1 W Signature Title C/�✓hes.,4 y .0pe�c� DOH-1555(07/18)p t of 2 / Public Health Law Sec. 4145(2b) � € 6 0 Receipt l Human remains of delivered on , 20 I. 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#