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Sadlocha, David Willaim
i NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David William Sadlocha Male Date of Death Age If Veteran of U.S.Armed Forces, 10/06/2020 73 Years War or Dates 1966-69 F Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address 20 Coolidge Avenue, Glens Falls,New York 12801 p Manner of Death © Natural Cause ❑Accident Homicide Suicide 0 Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title 0 Paul Filion MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 456 ❑Burial Date Cemetery,Crematory or Facility Name 10/07/2020 Pine View Crematory 0 Entombment Address ElCremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or and/or Held i Hold Address 01. Date Point of N L j Transportation Shipment p by Common Carrier Destination 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 5 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/07/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) 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: ATP'Z Date of Disposition IC /1 I7o Place of Disposition Vi" W (address) W Cl) (section) illot number) (grave number) Name of Sexton or Person in Charge , ' /r. L —�jMwlfi Q of Pre, es (ple4se print) W .J/ Title aiii 4119-9 t� Signature DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) " 1 4 3 rP 1 Receipt Human remains of delivered on , 20 } Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#