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Butchino, Mark C 0 LF- NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mark C.Butchino Male Date of Death Age If Veteran of U.S.Armed Forces, 08/05/2023 66 Years War or Dates 1975-1978 ZZ Place of Death Hospital,Institution or UJ City,Town or Village Hadley Town Street Address 41 Stony Creek Road, Hadley Town, New York 12835 p Manner of Death El Natural Cause Accident Ei Homicide Suicide Undetermined ❑Pending V Circumstances Investigation LU Medical Certifier Name Title George Siniapkin MD Address 604 Palmer Avenue,Corinth Town, New York 12822 Death Certificate Filed Town Of Hadley District Number Register Number City,Town or Village 4558 6 Burial Date Cemetery,Crematory or Facility Name 08/08/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town, New York Donation 0❑Removal Date Place Removed H and/or and/or Held N Hold Address 0 a. Date Point of CO N❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/08/2023 Registrar of Vital Statistics Colleen Demarsh(Electronically Signed) (signature) District Number 4558 Place Town Of Hadley I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition 8(q 113 Place of Disposition /, 1 (address) 6 111 U) Q (section) p (lot number) (grave number) 0 Name of Sexton or Person in Charge of Pre ises /1/*: � ,,('t1 Z /phase print/ W Signature Title g 1714 DOH-1555(07/18)p 1 of 2 e. 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#