Starkweather, David /. . N., # Z
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section ._
Name First Middle Last Sex
David George Starkweather Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/29/2018 66 War or Dates 1973 - 1977
Place of Death Hospital, Institution or
City, Town or Village Queensbury,NY Street Address 10 Sherwood Drive,Queensbury,NY
Manner of Death a Natural Cause 0 Accident ❑Homicide E Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
John P. Stoutenburg,MD
Address
'`' 102 Park Street,Glens Falls,NY 12801
Death Certificate Filed DistDislcict Number Fe ster Number
AlCity, Town or Village Town of Queensbury,NY 1 1
❑Burial Date Cemetery or Crematory
❑Entombment January 2, 2019 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
and/or Address
H Hold
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O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
O Permit Issued to Registration Number
3 Name of Funeral Home Regan Denny Stafford Funeral Home 01443
, Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is,hereby granted to dispose of the human remains described ove as indicated.
�' Date Issued I \ ;- 19 Registrar of Vital Statistics l .`-'(.
! °' ` (signature)
--
Q a District Numbec(�c m Place \ o 10-E Q L- -,� 0�
I certify that the remains of the decedent identified above were disposed of in accord c with this permit on:
Z
Date of Disposition I i 3 111 Place of Disposition f,,o.., l- „,t r;,,
III (address)
N
Ce (section) pII(lot number) (grave number)
pName of Sexton or Person in Charge of Premises i I,i, 0140
Z (please pint)'
Signature Title 0 `^0/L
(over)
DOH-1555(02/2004)