Connell, David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section d Burial - Transit Permit
Name First Middle Last Sex
David W. Connell Male
Date of Death Age If Veteran of U.S. Armed Forces, 1 9 6 8-7 0
0 6/2 9/2 01 1 61 War or Dates
}- Place of Death Milton Hospital, Institution or 331 Rowland St.
Z City, Town or Village Street Address
ILI0 Manner of Death❑Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
til Circumstances Investigation
at Medical Certifier Name Title
!� Michael Sikirica Dr.
qq
50 Broad StreetddrWaterford, NY 12188
Death Certificate Filed Milt on District Number _ / Register Number /-
City, Town or Village
❑Burial Date 0 7/01 /2 01 1 Cemetery or Crematory
PineView Crematory
❑Entombment Address
;;;;[ Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
and/or Address
t:: Hold
i'_
t3 Date Point of
ti❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Eii❑Reinterment Date Cemetery Address
>: Permit Issued to Zaumetzer-Sprague Funeral Home Registration Number
Name of Funeral Home 01892
Address
P.O. Box 127, Au Sable Forks, NY 12912
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
2 Address
M.
Iii
f. Permission is he eby ranted to dispose of the human remain- •escribe above as indi ted.
lig Date Issued /30/2()/ Registrar of Vital Statistics ►I'
y,
,(signature)
District Number 4.56, / Place / Gr1,0-4(:—/ 44.4. --1-(_
>::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ta Date of Disposition 1-C-P Place of Disposition Pri4Vu'i,' Crsrr4 to t 1�
2 (address)
LU
CO
IC (section) l (I t number"- (grave number)
el Name of Sexton or P son in Charg of Premises h t A " .3/ird
Z lease print)
t Signature Title 61ltib11tVL
(over)
DOH-1555 (02/2004)