Cameron, David I 4 4
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David Maxwell Cameron Male
`VP Date of Death ' Age If Veteran of U.S. Armed Forces,
01/08/2018 63 Years War or Dates
Place of Death Hospital, Institution or
6 City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death j Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
IA Medical Certifier Name Title
Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 12
.! ❑Burial Date Cemetery or Crematory
01/09/2018 Pine View Crematory
31,❑Entombment Address k
®Cremation Queensbury Town, New York
'3` Date Place Removed
❑Removal and/or Held
and/or
Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
4
c} Date Cemetery Address
❑Reinterment
aft Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
;` Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1,.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/09/2018 Registrar of Vital Statistics
5 g� �o6ert A Curtis(�ECectronically Signed)
TW (signature)
7 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 l/7 / Place of Disposition Ili)) a-v r Cwi L'/'.,-. ,la.may
rir
!7 , (address)
(section) (lot number) (grave number)
Name of Sexton or P r Charge of Premises '-I► -s" 64. 4&it"g-
/ (please print)
ro
Signature Title - !' ,--
(over)
DOH-1555 (02/2004)