Millington, David NEW YORK STATE DEPARTMENT OF HEALTH , . t 3
Vital Records Section Burial - Transit Permtt
Name First Middle Last Sex
David J. Millington Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 16,2017 66 War or Dates
'. Place of Death Hospital, Institution or
Z: City, Town or Village Glens Falls Street Address Glens Falls Hospital
ISi
3 Manner of Death I XI Natural Cause Accident I I Homicide Suicide Undetermined Pending
us Circumstances Investigation
w Medical Certifier Name Title
C Melissa Decker
Address
9 Carey Rd.,Queensbury,NY
. Death
Death Certificate Filed District Number Register,,[Vrger
City, Town or Village Glens Falls 5601 pc' ff
❑Burial Date Cemetery or Crematory
May 18,2017 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
9. and/or Address
H Hold
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O Date Point of
y Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
`° Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
4'- Remains are Shipped, If Other than Above
,S: Address
ar°
It'
A.
Permission is hereby granted to dispose of the human emains escrib above a- indicted.
Date Issued Registrar of Vital Statistics `74_, . -
fi,� (signature)
District Number J l Place '�,�� f U-42�� Ec-e--e -
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I certify that the remains of the decedent identified above w re disposed of in accordant with this permit on:
Z
tuDate of Disposition V* I n Place of Disposition qi ,,.. Z.•, oriv.,
2 (address)
co
re (section) 4 (lot number) ( (grave number)
Q Name of Sexton or Person in Charge of Premises l r.s �+41If
Z (ple se print)
w Signature 4 Title (READ jZft
(over)
DOH-1555 (02/2004)