Mahr, Clarissa N NEW YORK STATE DEPARTMENT OF HEALTH 1""
Bureau of Vital Records Burial - Transit Permit
Name First Middle
Last Sex
Clarissa N. Mahr
Date of Death Female
I Age If Veteran of U.S.Armed Forces,
08/11/2022 89 Years War or Dates
F.. Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls I Street Address Glens Falls Hospital
UQ Manner of Death a Natural Cause Accident Homicide Suicide
W Medical Certifier Name ❑Undetermined ❑Pending
Circumstances Investigation
O Title
Gamal Khalifa MD
Address
100 Park St,Glens Falls, New York 12801
Death Certificate Filed City Of Glens Falls District Number
City,Town or Village 5601 Register Number
416
Burial R
Entombment Date Cemetery,Crematory or Facility Name
08/13/2022 Pine View Crematory
Address
Cremation Queensbury Town, New York
Donation
oz❑Removal Date Place Removed
F- and/or and/or Held
- Hold Address _
0
d Date Point of
CO ElTransportation
Ci by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
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
2 Address
CC
W
E' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/12/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
WDate of Disposition 8I&5 l Z Z Place of Disposition j .,IL, ,ram
LU (address)
W
(I) (section) /lot number) (grave number)
a Name of Sexton or Person in Charge o Premises (4 r� ;11
O / /ple a print/
Z (r71Y/m t/d
W Signature �� Title
DOH-1555(o11181 p 1 of 2
r t '
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#