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Mock, Grace June NEW YORK STATE DEPARTMENT OF HEALTH 4 Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Grace June Mock Female Date of Death Age If Veteran of U.S.Armed Forces, 01/19/2024 74 Years War or Dates f_ Place of Death Hospital,Institution or Z City,Town or Village Chester Town Warren Street Address 242 Olmstedville Road,Chester Town Warren,New York 12860 W Manner of Death Undetermined Pendin W Natural Cause Accident1:1 Homicide Suicide g Circumstances Investigation W Medical Certifier Name Title Megan Rozell PA Address 4 Santanoni Drive,Newcomb Town,New York 12852 Death Certificate Filed Town Of Chester District Number Register Number City,Town or Village 5652 3 Burial Date Cemetery,Crematory or Facility Name 01/20/2024 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation OZ❑Removal Date Place Removed and/or and/or Held i- Hold Address 0 a. Date Point of V1 Transportation Q by Common Shipment Carrier Destination nDisinterment Date Cemetery Address I I Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/20/2024 Registrar of Vital Statistics Windy Conway(Electronically Signed) (signature) District Number 5652 Place Town Of Chester 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 111 2 (address) W C (section) n (lot number) (grave number) gName of Sexton or Person in Charge of Premises ! °J l^- Z /2 (pleOse print) W E Title Signature DOH-1555(07/18)p 1 of 2 en 117 74 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#