Bourgault, David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David Joseph Bourgault Male
Date of Death Age If Veteran of U.S. Armed Forces,
7/30/2015 84 War or.Dates No
t- Place of Death Hospital,:Institution or
City, Town or Village City of Albany Street Address Albany Medical Center
6 Manner of DeathI Natural Cause ❑Accident ❑Homicide ❑Suicide ri I--'Undetermined ❑Pending
ItCircumstances Investigation
ul Medical Certifier Name Title
O Harry DePan, MD
Address
43 New Scotland AVenue Albany, NY 12208
.. Death Certificate Filed District Number Register Number
>» City, Town or Village City of Albany 101 J 6c79
❑Burial Date Cemetery or Crematory
8/5/2015 Pine View Crematorium
❑Entombment Address
®Cremation Queensbury, NY
Date Place Removed .
Z=Removal and/or Held
0 and/or
Address
Cl)tt
Hold
(; Date Point of
Q 0 Li Transportation Shipment
G by Common Destination
Carrier _
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ii:: EliiM Permit Issued to Registration Number
Mi Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
68 Main St. PO Box 67, Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;'; Address
Cr
l
t3" Permission is hereby granted to dispose of the human remains described abo e as indi ted.
Date Issued Q J/-6J/an i c Registrar of Vital tatistics
(signet
igi District Number 10/ Place
�.. I certify that the remains of the decedent ide f e above were dispos of in accordance with this permit on:
Date of Disposition S f bi i2 Place of Disposition ILL (. or_
a (address)
l
V/
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises At 4400..., Si 6#4
z (phase print)
Signature f� Title r ► 11,-
(over)
DOH-1555 (02/2004) •