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Nawotniak, David NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex David Christopher Nawotniak Male Date of Death Age If Veteran of U.S. Armed Forces, November 19, 2016 69 War or Dates Vietnam F— Place of Death Hospital, Institution or W City, Town or Village Saratoga Springs Street Address WESLEY HEALTH CARE CENTER, INC W Manner of Death m iL.J Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title C Richard Teetz, M.D. Dr. Address Cambridge Famil" " Center Cambridge, NY 12816 Death Certificate Filed District Number 5^^ Register Number City, Town or Village -i ❑Burial Date Cemetery or Crematory November 22, 2016 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 N Date Point of pa,,, 0 Transportation Shipment CD: by Common Destination r Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address III Reinterment 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 1-- Remains are Shipped, If Other than Above 2 Address IX W> a' Permission is h reb granted to dispose of the human rem ' e ri d abete 'ndicate Date Issued 11 2 egistrar of Vital Statistics t (signature) District Number '""t ' Place Slr0, 't 0 < pIrr I nq S _ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Ws' Date of Disposition 11/22/2016 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) W'' 01 C (section) (lot number) (grave number) ciName of Sexton or Person in Charge of Premises 7t, ,Jaod:rf please print) W Signature 6/4' Title (l447+fRA (over) DOH-1555 (02/2004)