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Hull, Arthur L NEW YORK STATE DEPARTMENT OF HEALTH (:.!iii) Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Arthur L Hull Male Date of Death Age If Veteran of U.S.Armed Forces, 09/28/2021 72 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 311 West Mountain Road,Queensbury Town,New York 12804 p Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending Circumstances Investigation W Medical Certifier Name Title 0 Aimee Mcmaster Nurse Practitioner,Acute Care Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 201 ©Burial Date Cemetery,Crematory or Facility Name 10/01/2021 MountHermon Cemetery ElEntombment Address ❑Cremation Queensbury Town,New York Donation Removal Date Place Removed and/or and/or Held H N Hold Address 0 Q. Date Point of (A,❑Transportation Shipment $ by Common Carrier Destination Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above a Address ft W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/29/2021 Registrar of Vital Statistics Caroline 2fiGdegarie Barber(E(ectronically Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IH W Date of Disposition 1 0. 1 .202 place of Disposition 21 Quaker Rd. Queenshury, NY 1 24104 2 (address) W MT Hermon Family Plot (section) (lot number) (grave number) O Name of Sexto erson in Charge of Premises Connie Goedert O (please print) Signature Title Superintendent DOH-1555(07/8)p t of 2 Hull NAME Arthur Hull Age: 72 Lot Owner: Hull Family Lot# Mt Hermon Grave# Case: Concrete Died: 9,2 8.21 Interred: 1 0. 1 .21 Funeral Home: Regan Denny Stafford Cemetery: Mt Hermon