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Mahoney, Robert D - I:CO ,, 4. 20 NEW YORK STATE DEPARTMENT OF HEALTH _. Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Robert D.Mahoney Male Date of Death Age If Veteran of U.S.Armed Forces, 03/03/2023 69 Years War or Dates l— Place of Death Hospital,Institution or Z City,Town or Village Johnsburg Town Street Address Elderwood at North Creek 11.1 p Manner of Death EiNatural CauseAccident Homicide OSuicide Undetermined ❑Pending LU O Circumstances Investigation QMedical Certifier Name Title Leah Terry NP Address 4573 State Route 40,Argyle Town,New York 12809 Death Certificate Filed Town Of Johnsburg District Number Register Number City,Town or Village 5655 9 Burial Date Cemetery,Crematory or Facility Name 03/03/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town, New York Donation Z Date Place Removed Removal O ..adiq/or and/or Held H Hold Address 0 d Date Point of N El Transportation p by Common Shipment Carrier Destination 11 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake, New York 12842 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above g Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/03/2023 Registrar of Vital Statistics Jean M Comstock(Electronically Signed) (signature) District Number 5655 Place Town Of Johnsburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition Place of Disposition n1e v;`e, Cti,t•�f 2 (address W U) CC (section) of number) (grave number) O Name of Sexton or Person in Charg f Prem' es J��/�lDcu)� Z (please print) lL Signature 5see a Title Or ij DOH-1555(07/18)p 1 of 2 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#