Goble, Mark William NEW YORK STATE DEPARTMENT OF H EALTH �,°'--'F Burial - Transit Permit
Bureau
Vital tal Records
Name First Middle Last Sex
Mark William Goble Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/09/2022 56 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death ❑X Natural Cause ❑Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Jennifer Stratton MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 619
Burial Date Cemetery,Crematory or Facility Name
iiiiiim 12/15/2022 Pine View Crematory
Entombment Address
ECremation Queensbury Town,New York
Donation
0 EI Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
N❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
El
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
IH Remains are Shipped,If Other than Above
a Address
CC
IL
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/12/2022 Registrar of Vital Statistics Megan No(in(ECectronicaCCy 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:
I4—__
—
WDate of Disposition li zo I zL Place of Disposition .,,.
2 (ddress)
W
Cl) (section) / (lot number) `��w✓" (grave number)
8 Name of Sexton or Person in Charge of P ' s "
z (p se print)
W Signature Title ` li
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
0vs y " .a 3
Receipt
Human remains of delivered on , 20
Pine View emetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#