Wynn, David NEW YORK STATE DEPARTMENT OF HEALTid
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David Michael Wynn Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 7, 2012 61 War or Dates
Place of Death Hospital, Institution or
W
City, Town or Village Glens Falls Street Address
0 Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide D Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
Lt
Ili Medical Certifier Name Title
0 Michael Willen,
Address
1003 Loudon Road Latham, NY
Death Certificate Filed District Number Register Number
City, Town or Village 5601 S//
0 Burial Date Cemetery or Crematory
November 8, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
p Hold
0 Date Point of
❑Transportation Shipment
• by Common Destination
n Carrier
❑ Disinterment Date Cemetery Address
&W E ❑ Reinterment Date Cemetery Address
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
• Address
II}
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a. Permission is hereby granted to dispose of the huma(remains scribed a ovveeya�s in icate-.
��- ' Date Issued /
Registrar of Vital Statistics g ex_e_.�,� '// L
(signature)
District Number 5 01 Place 676,7f F4Y4 y /ate/
I certify that the remains of the decedent identified above w re disposed of in accordance with this permit on:
WDate of Disposition II/'I hi_ Place of Disposition -121, .L tc►.I (.+ vor,ur-.`
2 (address)
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(0 (section) _(lot number) (grave number)
Name of Sexton or Person in Charge Premises Ai oi- - S‘,411-
(p/ se print)
W' Signature Title CQ,1401r41Jt
(over)
DOH-1555 (02/2004)