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O'Brien, David W. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David W O'Brien 7Male Date of Death Age If Veteran of U.S.Armed Forces, 11/29/2019 90 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing lu p Mannerof Death © Natural Cause Accident ❑Homicide Suicide Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title Roslyn Socolof MD Address 42 Gurney Ln,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Villa a Queensbury ----75657 177 Burial Date Cemetery,Crematory or Facility Name 12/03/2019 Pine View Crematory Entombment Address XJ Cremation Queensbury Town,New York Donation z Removal Date Place Removed F and/or and/or Held N Hold Address O IL Date Point of N ❑Transportation jS by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above Address Q UU IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/03/2019 Registrar of Vital Statistics CaroCine Mifdegarde Barber(E(ectronicaCCy Signed) /signature/ District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ,I Date of Disposition 12 I15�11 Place of Disposition ZY., ( (-,t-, jaddressj W Q (sedion/ number/ (grave number/ 8 Name of Sexton or Person in Charge of Premises r f A."it , (PI-le print) Uj Signature L/ Title DOH-1555(07/18)p 1 of 2 i Public Health Law Sec. 4145(2b) 13 l'; `J s Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#