Hooper, David NEW YORK STATE DEPARTMENT OF HEALTH r - # 2(05--
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David G. Hooper Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 6,2015 74 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Schroon Lake Street Address 682 Charley Hill Road
Manner of Death ji' Undetermined Pending
pp �f� Natural Cause Accident Homicide Suicide
tti Circumstances Investigation
iw Medical Certifier Name Title
CV Joseph J. Schwerman MID
Address
,,, HIHIN,Schroon Lake,NY 12870
Death Certificate Filed District Number Register umber
.. City, Town or Village T/O Schroon Lake /56 3
❑Burial Date Cemetery or Crematory
Zdt8,2015 Pine View Crematory
Ei Entombment s
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
I.: Hold
Cl)
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
tt3 Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
a 3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I-' Remains are Shipped, If Other than Above
Address
Permission is re y granted to dispose of the huma ins described ab e as indicated.
Date Issued Registrar of Vital Statistics l-
(signature)
District Number t 6 3 Place T/O Schroon Lake,NY
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition q f'Jii• Place of Disposition ft ✓ e,...'0€
W (address)
U)
re (section) j (lot number (grave number
Q Name of Sexton or Person in Charge of Premises `—thri.. 3[w )
Z / (please print)
w Signature I1J Title ig.isitilDt
(over)
DOH-1555 (02/2004)