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Carpenter, David NEW YORK STATE DEPARTMENT OF HEALTH i 2 ti Vital Records Section ' Burial - Transit Permit Name First Middle Last Sex David Floyd Carpenter Male Date of Death Age If Veteran of U.S. Armed Forces, November 19, 2015 59 War or Dates I Place of Death rl Hospital, Institution or City, Town or Village Glens Falls Street Address 165 Maple Street Manner of Death u Natural Cause 0 Accident ❑ Homicide I I Suicide ❑ Undetermined 1--I Pending CircumstancesInvestigation Medical Certifier Name Title Timothy Murphy, Address 52 Haviland Ave Glens Falls, NY 12801 Death Certificate Filed District Number �Lool Regist�� City, Town or Village Glens Falls Date Cemete or Cremato ❑Burial November 23, 2015 Pine View Crematory ❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 2 ❑ Removal and/or Held Q and/or Address E Hold f Date Point of 2 ❑Transportation Shipment by Common Destination Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address ©' Permission is hereby granted to dispose of the human remains describe abo a nd' . Date Issued /%�2�3/27/5 Registrar of Vital Statistics ‘ ,o, (signature) District Number ice/ Place 6-7-er o A/5, -,,>` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 11/23/2015 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot numb (grave number) Name of Sexton or Person in Charg of Premises /t.r , s4 ( lease print) Si nature 4 / Title l l it 9 (over) DOH-1555 (02/2004)