Mahoney, Mavis J I. Ca
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records , . Burial - Transit Permit
Name First Middle Last Sex
Mavis J.Mahoney Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/15/2022 88 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Johnsburg Town Street Address 448 Goodman Road,Johnsburg Town, New York 12843
W
p Manner of Death Natural Cause Accident Homicide Suicide FlUndetermined Pending
W
V Circumstances Investigation
W Medical Certifier Name Title
G Lauren Winn MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Johnsburg District Number Register Number
City,Town or Village 5655 23
Burial Date Cemetery,Crematory or Facility Name
1. 08/17/2022 Pine View Crematory
Entombment Address
aCremation Queensbury Town,New York
Donation
oRemoval Date Place Removed
and/or and/or Held
H Hold Address
0
O. Date Point of
Cl) Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped,If Other than Above
2 Address
C
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/16/2022 Registrar of Vital Statistics jean gvt Comstock(ECectronicallySigned)
(signature/
District Number 5655 Place Town Of Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
RI
of Disposition 4i11I 2L Place of Disposition T "�
2 (address)
W
CO
EC (section) /1 (lot number) (grave number)
SName of Sexton or Person in Charge of remises t a! �i�
Z /� / /ease print) �q,,�
W Signature G_I _/�---� Title l n'�� �
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
•
Human remains of ; ` 20
�' delivered on ,
Pine View Cemetery Representing the funeral home named ot},burial permit
Official Funeral Directors Reg.or License#