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Weaver, Donald NEW YORK STATE DEPARTMENT OF HEALTH, _ 1 4 KZ Vital Records Section Burial - Transit Permit T Name First Middle Last Sex Donald D. Weaver Male Date of Death Age I If Veteran of U.S. Armed Forces, September 17,2012 85 War or Dates World War II Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital a. Manner of Death JJVatural Cause Accident I !Homicide Suicide n Undetermined Pending US Circumstances Investigation q Medical Certifier Name G�� Title 121 Address/ 45$J �fGL� .o 7 Q/"�c%�iL/ ij' ' iqI°I Death Certificate Filed District Number RegisterN ber • City, Town or Village Glens Falls 6301 L'" 7 V5- , ❑Burial Date Cemetery or Crematory ❑Entombment September 18, 2012 Pine View Crematorium Address ©Cremation 21Quaker Road, Queensbury,NY 12804 Date Place Removed ZZ r7 Removal and/or Held and/or Address H Hold U) O Date Point of NE Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 • Address 407 Bay Road, Queensbury, NY 12804 • Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above E Address eZ tit IX Permission is her by ranted to dispose of the human r ains des bed ab ve as indicated. Date Issued Of /c( O/}_.Registrar of Vital Statistics a' i (signature) District Number 6301 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ,I III Date of Disposition 9-f g-(t Place of Disposition R.L Uievl C�.",,i-a riN__ 2 (address) co re (section) ` (lot number) (grave number) pName of Sexton or Person in Charge of Premises ,I obi �w�t}' 'Z (please print) Signature ' 4 Title Camp/ (over) DOH-1555(02/2004)