Zack, David it LL7
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David Zack Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 9, 2011 68 War or Dates
"':: Place of Death Hospital, Institution or
: City, Town or Village Glens Falls Street Address Glens Falls Hospital
; Manner of Death I XI Natural Cause Accident I I Homicide Suicide 1- Undetermined Pending
Circumstances Investigation
ES
Medical Certifier Name Title
Christopher Hoy MD
P. Address
102 Park Street Glens Falls NY
• Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 c2J
❑Burial Date Cemetery or Crematory
May 11, 2011 I Pine View Crematorium
❑Entombment Address
D Cremation 21Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
0 Date ' Point of
n Transportation I Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I II
• Permit Issued to Registration Number
" Name of Funeral Home Singleton-Healy Funeral Home 1 01622
Address
°-a' 407 Bay Road, Queensbury, NY 12804
E°=:• : Name of Funeral Firm Making Disposition or to Whom
k + Remains are Shipped, If Other than Above
E. Address
11
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Permission is he eb granted to dispose of the human rem me described above als indicated.
Date Issued ,�j /e d�/j Registrar of Vital Statistics Lam, / ��
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z +�
LU Date of Disposition 5-q-(( Place of Disposition 2,..U <<t.) £ ' t'�"0tIv._
(address)
W
CO
re
0 (section) /f i(lot number) (grave number)
ap Name of Sexton or Person in Charg of Premises C/11,E t,�1�`',►('�Ai „•tti -
Z 1 (please print)
- W Signature Title CilENi lip&
(over)
DOH-1555(02/2004)