Spatol, David t
NEW YORK STATE DEPARTMENT OF HEALTH �cc
Vital Records Section Burial - Transit Permit
rrr Name First Middle Last Sex
David J. Spatol Male
rf:: Date of Death Age If Veteran of U.S. Armed Forces,
�:a` April 3,2016
i 65 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
ti
Lynn M.Keil RNAC
Address
126 Ski Bowl Road,North Creek,NY 12853
$"r Death Certificate Filed District Number Register Number
: _ City, Town or Village 5 o 1 Z 9
❑Burial Date Cemetery or Crematory
❑Entombment April 5,2016 Pine View Crematory
Address
0 Cremation Quaker Road, Queensbury
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
U
0 Date Point of
c Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
a Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
aze� 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
tid Remains are Shipped, If Other than Above
IAddress
,.r::: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued L) f ,S 120! C Registrar of Vital Statistics ( A W../�-e,{-f
�e
(signature) U
District Number s 60 r Place 6 c �j t\ S 0 7
tf i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition IA '1 Place of Disposition Fro tA./ (,Pm+G al..
W (address)
U)
ZtY (section) (lot numbs (grave number)
Z Name of Sexton or Person in Charge of Premises ��s W.*
( lease print)
Signature a Title 4 _
(over)
DOH-1555(02/2004)