Loading...
Dickerson, Donald K. -471 1—) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donald K Dickson Jr Male Date of Death Age If Veteran of U.S.Armed Forces, 10/13/2020 57 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital ILI p Manner of Death ©Natural Cause ElAccident ❑Homicide ❑Suicide Undetermined Pending W C.) Circumstances Investigation UJ Medical Certifier Name Title 0 Marvin Davidowitz MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 467 ❑Burial Date Cemetery,Crematory or Facility Name 10/15/2020 Pineview Crematory ElEntombment Address Cremation Queensbury,New York Donation Z El Removal Date Place Removed and/or and/or Held F— N Hold Address • 1-1 O Date Point of Cl) ❑Transportation • by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 5 Address CC uJ a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/14/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition %O/1i,11° Place of Disposition 2 (Ties/ W CC CC (section) 4►lotn tuber/ (grave number) O Name of Sexton or Person in Charge Premises a twig �j (pie e pri krAir Signature (f' Title - DOH-1555(07/18)p t of 2 _,, y Public Health Law Sec. 4145(2b) _4 1 t 9 Receipt P Human remains of ' ' delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# '