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Mulcahy, Jeremiah Francis Jr. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeremiah Francis Mulcahy Jr Male Date of Death Age If Veteran of U.S.Armed Forces, 08/27/2022 70 Years War or Dates 1. Place of Death Hospital,Institution or Z City,Town or Village Fort Ann Village Street Address 99 County Rt 16,Fort Ann Village,New York 12827 111 0 Manner of Death II Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending W Circumstances Investigation U W Medical Certifier Name Title CI Paul Filion MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed Village Of Fort Ann District Number Register Number City,Town or Village 5723 2 X Burial Date Cemetery,Crematory or Facility Name 09/01/2022 Pine View Cemetery Entombment _ Address Cremation Queensbury,New York DDonation Removal Date Place Removed and/or and/or Held pN Hold Address M❑Transportation Date Point of a by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom f Remains are Shipped,If Other than Above 2 Address CC W 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/30/2022 Registrar of Vital Statistics BarbaraI Winched(ECectronicaaySigned) (signature) District Number 5723 Place Village Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition q,_ r. 'aa cc Place of Disposition ' l uc <c'Q Rp © 1_,cr_I-f4r,jC,y� 1 a't�'`` Ui 2 (address)� v Ili Ri C 6' 1 cr (section) �(lot number), (grave number) 8 Name of Sexton or Person in Charge of Premises CE3rIrti4' �1 \ , 1 Z (please print) f _ , W Signature /� Title za Qe f !/\ 1 L DOH-t555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 0,12941 E1 2 9 4 1 Receipt 1 Human remains of .V"'i', -`,�.:.�-, :.-4..:-.-- delivered on 1 i , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# ', MULCAHY NAME Jeremiah F. Mulcahy Age:70 Lot Owner:Jeremiah Mulcahy & Gail Madison Lot# Erie 80 G Grave# 1 Case: Concrete Died: 8.2 7.2 2 Interred: 9. 1 .2 2 Funeral Home: Singleton Sullivan Potter Cemetery: Pine View