Plude, David 1 / # 2'7(
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
It Name First Middle Last Sex
David Plude Male
l Date of Death Age If Veteran ( "U.S. Armed Forces,
March 30, 2017 71 War or Dates
F- Place of Death Hospital, Institution or
WCity, Town or Village Queensbury Street Address 86 Boulevard
ei Manner of Death 0 Natural Cause ❑ Accident I:: Homicide ❑ Suicide ❑ Undetermined El 1-1 Pending
C CircumstancesInvestigation
W Medical Certifier Name Title
Lauren Hendershot, FNP-BC,
Address
Death C rtificate FilerzA Di t Number fie ister Number
wn Ci , o �,r Villages. c(Skc- '� �'�p�
❑Buna Date Cemetery or Crematory
April 3, 2017 I Pine View Crematorium
*❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold Pine View Crematorium
lyi
Date Point of
Transportation Shipment
0.1 by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
,rf Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
l-= Remains are Shipped, If Other than Above
ZE Address
ir
a Permission is hereb granted to dispose of the human remai s described above s indicated.
Date Issued 1 1 -, Registrar of Vital Statistics ( _
.—_—___„ (signature)
District Number (Q ') Place ) O L.,, n LA �,,, ' s_
I certify that the remains of the decedent identified above were disposed of in acc• dan•- with this permit on:
,w. Date of Disposition 04/03/2017 Place of Disposition Quaker Road Queensbury,NY 12804
` (address)
(section) ii (lot number) (grave number)
la Name of Sexton or Person in Charge of P emises iini kr J Grim I'
(phase print)
IP Signature LI H Title CFf(nFt0 .-
(over)
DOH-1555 (02/2004)