Snyder, David NEW YORK STATE DEPARTMENT OF HEALTH # 5 35
Vital Records Section Burial - Transit Permit
tgo Name First Middle ; Last Sex
David Louis Snyder Male
Date of Death Age If Veteran of U.S. Armed Forces,
tig October 29, 2011 54 War or Dates
Place of Death Hospital, Institution or
Ci , Town or Village C/ees/(/ls,. Ay- Street Address Glens Falls Hospital
Manner of Death E Natural Cause El Accident 0 Homicide 0 Suicide n Undetermined Pending
Circumstances Investigation
I t Medical Certifier Name Title
Daniel Way, Dr.
gli Address
04 Skibowl Road North Creek, NY 12853
D--th Certificate Filed District NumberRegister trNumber
Town or Village6/P/2s /'//s, ,L clee/ J .f
I Burial Date Cemetery or Crematory
October 31, 2011 Pine View
0 Entombment Address
z®Cremation Quaker Road Queensbu NY 12804
rY,
Date Place Removed
Removal and/or Held
and/or Address
) Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
14)
Disinterment Date Cemetery Address
ReintermentArt- Eil Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, if Other than Above
Address
Permission is hereby granted to dispose of the human re ins de ibed abov as indicate"
( )
PI Date IssuecI2'/3// // Registrar of Vital Statistics _e�,
_ (signature)
District Number �j�f` Place 'l�gS /Z/f j/' AVO r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/31/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (p , (lot num (grave number)
Name of Sexton or Pers in Charge of remises hc5-k t4
' (please print)
Signature Title Cepmicito(_
(over)
DOH-1555 (02/2004)