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Fuller Sr. Daniel Stevenson NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Daniel Stevenson Fuller Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 04/27/2020 81 Years War or Dates 1955-1957 Place of Death Hospital,Institution or W City,Town or Village Kingsbury Town Street Address 3152 County Route 43, Kingsbury Town,New York 12827 p Mannerof Death ©Natural Cause Accident Homicide Suicide ❑Undetermined Pending Circumstances Investigation W Medical Certifier Name Title James North MD Address 100 Broad Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 14 Burial Date Cemetery,Crematory or Facility Name 04/29/2020 Pine View Crematorium Entombment Address Cremation Queensbury Town,New York Donation ZO Removal Date Place Removed and/or and/or Held V)N Hold Address O a Date Point of ❑ V) Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition orto Whom F.. Remains are Shipped,If Otherthan Above 2 Address M- W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/29/2020 Registrar of Vital Statistics CyntkiaA Bardin(ECectronicaCCySigned) (signature) District Number 5762 Place Kingsbury Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: z �Iz��Za Date of Disposition Place of Disposition ZL W W (address) W cc (section) (lot n/u�yrberl (grave number/ 0 Name of Sexton or Person' WChegfPre isesZ /p/ a print/ W Signature Title DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 01 13166 � Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# "