Mason, Dennis J ; )
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dennis J.Mason Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/27/2022 45 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
pManner of Death ❑W ❑ ❑ ❑Undetermined Pending Natural Cause Accident Homicide II Suicide
Circumstances Investigation
W Medical Certifier Name Title
CI Timothy Cavanaugh Coroner
Address
112 State Street,Albany,New York 12207
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 2506
Burial Date Cemetery,Crematory or Facility Name
11/04/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
- Hold Address
N
0
a. Date Point of
to❑Transportation
Q by Common Shipment
Carrier Destination
El
Disinterment
Date Cemetery Address
EI
Reinterment
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
N Remains are Shipped,If Other than Above
2 Address
IlLI
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/31/2022 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition II 1 1 17Z Place of Disposition
W
2 (address)
W
N
CC (section) /I (lot number)C (grave number)
Name of Sexton or Person in Charge of P ises
Z lease print)
W
Signature Title ( -/01177/rL
DOH-1555(o7/18)p t of 2
- -,
'7; 1 "?ti 76
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#