Mattson, Steven Lars 1f�36
NEW YORK STATE DEPARTMENT OF HEALTH � Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Steven Lars Mattson Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/24/2022 77 Years War or Dates
u_ Place of Death Hospital,Institution or
Z City,Town or Village Stony Creek Town Street Address 11 Hilderbrandt Road,Stony Creek Town,New York 12878
UJ
W Manner of Death ❑X Natural Cause nAccident Homicide Suicide Undetermined Pending
CI Circumstances Investigation
W Medical Certifier Name Title
C Curtis Gedney MD
Address
454 Glen Street,Glens Falls,New York 12801
Death Certificate Filed Town Of Stony Creek District Number Register Number
City,Town or Village 5658 8
Burial Entombment
Date Cemetery,Crematory or Facility Name
12/30/2022 Pine View Crematory
Address
▪Cremation Queensbury Town,New York
▪Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
N Transportation
p by Common Shipment
Carrier Destination
O
Disinterment
Date Cemetery Address
EI
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
— Remains are Shipped,If Other than Above
2 Address
It
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/29/2022 Registrar of Vital Statistics Susan I.?farrington(EYectronicaR:y Signed)
(signature)
District Number 5658 Place Town Of Stony Creek
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition /Z-3It02 Place of Disposition ✓J e Vi e.4..) ire/Ada
2 (address)
W
N
IX (section)�a /(lot number) (grave number)
gName of Sexton or Person in Char f Premises K'ci t r✓� G✓a�D(i
(please print)
z �'
Signature �j` Title cees- .. S
DOH-1555(07/18)p 1 of 2 /
'°v A s1
Public Health Law Sec. 4145(2bj
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#