Fisher, David NEW YORK STATE DEPARTMENT OF HEALTH
», Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David L. Fisher Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/16/2012 90 years War or Dates 1942-1946
:f P e of Death Hospital, Institution or
:ZAS.
Tow il Street Address
XX Glens Falls Park St Glens Falls, N Y
CI v anner of Death Iai Natural Cause Accident Homicide Suicide Undetermined Pending
1U J� Circumstances Investigation
tu Medical Certifier Name Title
O Farhana Kamal M D
Address
Glens Falls Hospital 100 Park Street Glens Falls
De Certificate Filed District Number Register Number
it own) yiiwialititxx Glans Falls 5601 169
iiiiiiiiii Byirial Date Cemetery or Crematory
�Entornbrrsr+.t 04/19/2012 Pine View Cemetery
iiiiiiiiii Address
iiiiiiiiii IDCremation . Queensbury. NY 12804 •
Date Place Removed
Z Removal and/or Held
9.!❑and/or
Address
Hold
O Date Point bf
d 0 Li Transportation Shipment
e3 by Common Destination
iiiiiiiiii Carrier
gi
Q Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
iiiiiiiiiiPermit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
iiiiiiiiii Address
P O Box 277 Fort Ann, N Y 12827
iinii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tr
I
P` Permission is hereby granted to dispose of the human remains describ d bove s in ted.
niiii Date Issued 04/17/2012 Registrar of Vital Statistics
/ (signature)
iiM District Number 5601 Place Glens Falls /G17 /0/Sid J
II certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
tii Date of Disposition 4/1 8/1 2 Place of Disposition Pine View Cemetery
(address)
in
tO Uncas Sec. 22 937 1
CC • (section) (lot number) (grave number)
f Name of Sexton or Perso in Charge of Premises
i� 9 Michael Genier
► _ (please print)
iii Signature A- Title Superintendent
(over)
DOH-1555 (0?/2004)