Jaswaye, David NEW YORK STATE DEPARTMENT OF HEALTH = ► ii 0 13
Vital Records Section 0. ' '4, Burial - Transit Permit
Name First Middle Last Sex
David Alexander Jaswaye M
Date of Death Age If Veteran of U.S. Armed Forces,
11/09/2017 76 War or Dates ``i5'S - l 9 6 2
1. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address 40 Chester St.
`p Manner of Death Natural Cause E Accident n Homicide I I Suicide n Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
G Timothy Murphy Coroner
Address
52 Haviland Ave,Glens Falls,NY 12801
Death Certificate Filed District Number Register NA,Jimber
City, Town or Village Glens Falls 5601 5
❑Burial Date Cemetery or Crematory
Entombment 11/14/2017 Pine View Crematory
Address
®Cremation Quaker Rd.Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Date Cemetery Address
1-1 Disinterment
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IL
Permission is ereby granted to dispose of the hum remain descri d above as Indic:ted.
Date Issued 3 Registrar of Vital atistics ,",i--) / Dr�J`-(,
(s gna ure)
District Number 56 ( Place Ls, c%' 4 `
I—
I certify that the remains of the decedent identified above ere disposed of in accordance ith this permit on:
w Date of Disposition /i J li I q Place of Disposition 4?�,V.,) .+Yrc,�f.�
(address)
W
CO
re (section) ill (lot number) (grave number)
p Name of Sexton or Person in Charge of Pre ises r.; ,, S s,�'
l 4
Z (please print)
W4
Signature 1,� Title A2EYht�Q�
(over)
DOH-1555(02/2004)