Davis, Merrill J. • - A Igo
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Merrill J.Davis Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/27/2020 93 Years War or Dates 1944-46
� Place of Death Hospital,Institution or
WCity,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
`p Mannerof Death ®Natural Cause Accident Homicide Suicide Undetermined Pending
V Circumstances Investigation
Q Medical Certifier Name Title
Leonard Gelman MD
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville 5756 12
❑Burial Date Cemetery,Crematory or Facility Name
❑
02/28/2020 PineView Crematorium Entombment Address
Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
�- Hold Address
N
O
0. Date Point of
N R Transportation
Q by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
ft
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/28/2020 Registrar of Vital Statistics Jenny Linda Martelle(Electronically Signed)
(signature/
District Number 5756 Place Granville, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F—
WDate of Disposition Z 1g)10 Place of Disposition t_
(address)
W
NIIX (sed/on) n (lot number/ (grave number)
0 Name of Sexton or Person in Charge of Premises t
Z ,J,� (pl se print)
W Signature L./` Title AcoAMt
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 13 3 6
Receipt
Human remains of . ' ' - ' delivered on >t , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#