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Wilusz, David C.
3 A - 4 NEWYORK STATE DEPARTMENT OF HEALTH Burial - Trans Bureau of Vital Records it Permit Name First Middle Last Sex David C.Wilusz Male Date of Death Age If Veteran of U.S.Armed Forces, 04/09/2020 38 Years War or Dates ZPlace of Death Hospital,Institution or City,Town or Village Saratoga Springs Street Address 125 West Avenue 137, Saratoga Springs,New York 12866 Q Manner of Death Natural Cause Accident Homicide Suicide Undetermined ©Pending W C.) Circumstances Investigation GMedical Certifier Name Title David DeCelle Coroner Address 40 McMaster Street,Ballston Spa,New York 12020 Death Certificate Filed F4501 trict Number Register Number City,Town or Village Saratoga Springs 216 Burial Date Cemetery,Crematory or Facility Name 04/14/2020 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York Donation 0 ❑Removal Date Place Removed and/or and/or Held H asHold Address O IL N FlTransportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg, New York 12885 Name of Funeral Firm Making Disposition or to Whom E-• Remains are Shipped,If Other than Above Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/13/2020 Registrar of Vital Statistics John 2aulTranck(ECectronicaCCy Signer (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition 13 110 Place of Disposition R rl9_- i p r W 2 (address) W W (section) (/otnumber) (grave number) �j Name of Sexton or Person in Charge of r mises >rQ13 C-TT` Z (Please print) W Signature Title DOH-1555(07/18)p 1 of 2 i Public Health Law Sec. 4145(2b) 013532 Receipt 1 Human remains of delivered on , 20 Pine View Cemetery RepfesentiQ the funeral home named on burial permit Official Funeral Directors Reg.or License#