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Myers, Mark Austin 1.,..,.tNEW YORKSTATE DEPARTMENTOF HEALTH 4Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mark Austin Myers Male Date of Death Age If Veteran of U.S.Armed Forces, 10/30/2023 51 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 126 Mountain View Lane,Queensbury Town,New York 12804 tU p Manner of Death ONatural CauseAccident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title C3 Timothy Murphy Coroner Address 52 Haviland Avenue,Glens Falls,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 167 Burial Date Cemetery,Crematory or Facility Name 11/06/2023 Pine View Crematory Entombment — Address ©Cremation Queensbury Town,New York Donation 0Z❑Removal Date Place Removed and/or and/or Held H Hold Address to 0 a Date Point of U)0Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ❑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 F Remains are Shipped,If Other than Above M Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/06/2023 Registrar of Vital Statistics Caroline IfiCdegarde Barber(Etectronically 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: Z Date of Disposition II i1 I73 Place of Disposition f�N J "A(l2d"-- IL M (address) W CC (section) 41(lot number) d� (grave number) aName of Sexton or Person in Charge of Premise 4 n n 1 (ple a print) W Signature l� 1, Title (t F 'M)V V - DOH-1555{07/18)p 1 of 2 n 7 6 4 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# = ,