Sullivan, Mark Edward 4# 13
NEW YORKSTATE DEPARTMENT OF HEALTH k Burial - Transit Permit
Bureau of Vital Records s.,` ' 1
Name First Middle Last Sex
Mark Edward Sullivan Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/18/2023 64 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
ILI
0 Manner of Death ❑X Natural Cause Accident 0 Homicide OSuicide ❑Undetermined Pending
iU
Circumstances Investigation
E Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 11
Burial Date Cemetery,Crematory or Facility Name
01/19/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
and/or and/or Held
H
N Hold Address
0
a. Date Point of
U)ElTranspoitation Shipment
Ei by Common
Carrier Destination
Date Cemetery Address
Disinterment
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
t` Remains are Shipped,If Other than Above
2 Address
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/19/2023 Registrar of Vital Statistics Caroline HYdegarrfe Barber(E(ectronica1TySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition I I Z3 13 Place of Disposition 't1L,
1,IJ g (address)
W
NEt (section) (lot num (grave number)
Name of Sexton or Person in Charge of P7remises
Av.
C.-- NZ ( ease print)
W Signature Title <eymcizr,
DOH-1555(o7/18)pi of 2
},) •_ .)I)/0 0
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#