Cooper Sr., David B. w
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David B.Cooper Sr. I Male
Date of Death Age If Veteran of U,S.Armed Forces,
01/24/2020 66 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Wilton Town Street Address 121 Edie Road,Wilton Town,New York 12866
upMannerof Death ❑X Natural Cause Accident ❑Homicide ❑Suicide El Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
Tracey Brennan MD
Address
324 West Avenue,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Gansevoort 4569 2
Burial Date Cemetery,Crematory or Facility Name
01/29/2020 Pine View Crematory
Entombment Address
RI Cremation Queensbury Town,New York
Donation
ZO Fj Removal Date Place
Hold
ace Removed
and/or a
F—CO) Hold Address
O
G- Date Point of
N ElTransportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition orto Whom
l— Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/27/2020 Registrar of Vital Statistics Swan Ballwin(EketronicaQ Srgr7er9
(signature)
District Number 4569 Place Gansevoort, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 1131 17o Place of Disposition ;w ti,�csv�
W (address)
2
W
O (section) i (tot number) (grave number)
hi—
Name of Sexton or Person in Charge of Premises P
(p! se print)
W ko
Signature Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 913295
Receipt
Human remains of ' delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#