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Basso, Mark L if 306 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mark Basso Male Date of Death Age If Veteran of U.S.Armed Forces, 03/22/2023 57 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 10 Judmar Lane,Queensbury Town, New York 12804 ILI p Manner of Death ❑X Natural Cause Accident 0 Homicide ESuicide nUndetermined ElPending W Circumstances Investigation W Medical Certifier Name Title O Paul Bachman MD Address 9 Carey Rd,Queensbury Town,New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 49 Burial Date Cemetery,Crematory or Facility Name 03/30/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held NHold Address 0 Date Point of U)❑Transportation Shipment b by Common Carrier Destination ODisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/30/2023 Registrar of Vital Statistics Caroline 9fi(fegarde Barber(Electronically Signed) (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:I— r- Z Date of Disposition v./ )23 Place of Disposition FJ e v eJ Ct-�1d (�"\ 2 (address) W IDCC (scion) (tot nu ber) (grave number) G Name of Sexton or Person in Charge Premix (please(P P Z - /� '/p W Signature Title C�,(lt?�+.Yar DOH-1555(o7/18)p 1 of 2 1 N II.- my x f c4 Public Health Law Sec. 4145(2b) 1 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#