Terry, David NEN,YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
David Terry Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 9, 2013 55 War or Dates
!r Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death fJ Natural Cause Accident Homicide Suicide Undetermined n Pending
Circumstances Investigation
8. Medical Certifier Name Title
O Eric Pillemar MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 3 ' /.�
X Burial Date Cemetery or Crematory
08/17/2013 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Rd, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
y El Transportation Shipment
a by Common Destination
Carrier
El
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
Address
t
w
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/12/2013 Registrar of Vital Statistics CA.)
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 8/1 7/1 3 Place of Disposition Pine View Cemetery
W (address)
Unadilla 8 B 3
M (section) (lot number) (grave number)
Q Name of Se n or Person in Charge of remises Connie L. Goedert
`Z (Please print)
Sigi?ature` Title Superintendent
(over)
DOH-1555(02/2004)