Mach, Robert Walter Sr. llo
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert Walter Mach Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/02/2022 77 Years War or Dates NationalGuard
F-• Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
pManner of Death ❑X Natural Cause Accident p Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
CMedical Certifier Name Title
Jennifer Donovan DO
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 28
Burial Date Cemetery,Crematory or Facility Name
02/07/2022 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
d. Date Point of
co) ❑Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
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
1— Remains are Shipped,If Other than Above
Address
LC
W
L' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/07/2022 Registrar of Vital Statistics Caroliinexkkgarf Barb-er({YectronrcallySigned)
(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 a Place of Disposition D;A
2 I (address)
W
N CC (section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises �Q,�/h�tV 54►t;r�
Z (please print)
W Signature Title re,Pty jr
DOH-1555(07/18)p 1 of 2
0 . 5 6F 1.2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
i
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#