Howard, David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David Howard Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/11/2018 89 Years War or Dates
Place of Death Hospital, Institution or
- City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Philip Gara MD
Address
319 Broadway, Fort Edward Town, New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 44
. ®Burial Date Cemetery or Crematory
08/16/2018 Pine View Cemetery
❑Entombment Address
❑Cremation Queensbury Town, New York
Date Place Removed
❑Removal
and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/14/2018 Registrar of Vital Statistics Aimee Mahoney(cEfectronicaltySigned)
(signature)
• District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 8/1 6/2 01 8Place of Disposition Pine View Cemetery Queensbury
(address)
Erie 25-D 1
(section) (lot number) (grave number)
Name of Sext n or Person in Charge of Premises
Connie Goedert
(please print)
CemeterySuperintendent
• Signature Title
(over)
DOH-1555 (02/2004)