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Davis, Mark Raymond r r,ti 4913 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mark Raymond Davis Male Date of Death Age If Veteran of U.S.Armed Forces, 11/19/2023 58 Years War or Dates ZPlace of Death Hospital,Institution or City,Town or Village Queensbury Town Street Address 253A John Burke Apartments,Queensbury Town,New York 12804 ttp Manner of Death ❑X Natural Cause Accident Homicide ESuicide Undetermined Pending Circumstances Investigation WMedical Certifier Name Title Thomas Portuese MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 171 Burial Date Cemetery,Crematory or Facility Name 11/21/2023 Pine View Crematory Entombment Address ©Cremation Queensbury,New York Donation g❑Removal Date Place Removed and/or and/or Held _ F Hold Address CA 0 d Date Point of Cl)OTransportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address OReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If.Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/21/2023 Registrar of Vital Statistics Caroline xYclegarde Barber(E(ectronical(ySigned) (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 Z3 Place of Disposition 1\)e 14e1=0 Cry yrUi'AT(►� 2 (address) W CO (section) (lof number) (grave number) SName of Sexton or Person in Chyyes -P�'y/jib titre/ Z (please print) W Signature Title b er440 DOH-1555(07/18)pi of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 PineiView Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#