Morrnhinweg, David NEW Y&RK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David Morrnhinweg Male
<1' Date of Death Age If Veteran of U.S. Armed Forces,
April 25, 2014 81 War or Dates
1,,, Place of Death Hospital, Institution or
City, Town or Village Ft. Edward Street Address Fort Hudson Nursing Home
Manner of Death n n ❑Undetermined Pending
Cause Accident Homicide Suicide
Circumstances Investigation
w Medical Certifier Name Title
Phillip J. Gara Dr.
Address
• 327 Broadway,Fort Edward,NY 12828
• Death Certificate Filed District Numbe5755 Register Number
City, Town or Village Fort Edward 3[-a-
E Burial I Date Cemetery ur Crematory
April 29, 2014 Pine View Cemetery
III Entombment
Address
❑Cremation Quaker Road, Queensbury, , NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
CO• Transportation Shipment
p by Common Destination
Carrier
Li 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 Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ri
• Permission is hereby ranted to dispose of the human re ains described above as indicated.
Date Issued �l � t4 Registrar of Vital Statistics c
(signature)
District Number 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
WW Date of Disposition 4/2 9/1 4 Place of Disposition Pine View Cemetery
W (address)
U) Erie 48B 1
0 (section) (lot number) (grave number)
QName of xton or Person in Charge of Premises Connie L. Goedert
(please print)
W Signat Title Superintednent
(over)
DOH-1555(02/2004)