Slater, David I37
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David S Slater Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/10/2018 74 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
ig 9 p�
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 73
❑Burial Date Cemetery or Crematory
02/12/2018 Pineview Crematory
DEntombment Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
". Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home Inc 00885
Address
46 Williams Street,Whitehall Village,New York 12887
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
ter:
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/12/2018 Registrar of Vital Statistics &denA Curtis(E(ectronicaffySigned)
(signature)
ipa District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Z)ii Place of Disposition 174,,�
(address)
(section) j� (lot numb (grave number)
Name of Sexton or Person in Charge of remises l 4Pis 4_,- s.,i(f
()Pease print)
Signature Title Min i bL
(over)
DOH-1555 (02/2004)