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NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Matthew R Hayes Male
Date of Death Age If Veteran of US.Armed Forces,
12/21/2022 58 Years War or Dates
ZPlace of Death Hospital,Institution or
IJJ City,Town or Village Wilton Town Street Address 9 Tom Sawyer Drive,Wilton Town,New York 12831
p Manner of Death j Natural Cause ❑Accident Homicide Suicide Erndetermined Pending
0ircumstances Investigation
QW Medical Certifier Name Title
Hannah Dodge DO
Address
200 Broad Street,Schuylerville Village,New York 12871
Death Certificate Filed Town Of Wilton District Number Register Number
City,Town or Village 4569 92
Burial Date Cemetery,Crematory or Facility Name
v 12/23/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Ei Removal Date Place Removed
and/or and/or Held
F Hold Address
N
0
O. Date Point of
(I)❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
fH Remains are Shipped,If Other than Above
2 Address
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n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/22/2022 Registrar of Vital Statistics Susan Baldwin(Electronically Signed)
(signature)
District Number 4569 Place Town Of Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Z Date of Disposition ,z,3_4,7� Place of Disposition e,�e ✓�et.,) Cr. ab tt-�vv((
(address1-4
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Q (section)---- (lot number) (grave number)
0 Name of Sexton or Person in Charge of Pre 'ses I C/��/YI v.^� l� l�Cx.cl
Z (please print)
W Signature �� Title Cy-d-K-
DOH-1555(07/18)p 1 of 2
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IPublic Health Law Sec. 4145(2b)
Receipt
i
y Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#