Winchell, Dave 4 LvY • nos .
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section 1 Burial - Transit Permit
iiiii Name First Middle Last Sex
iiiiZ Dave Winchell Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 26, 2014 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
P. Frances C.Bollinger
Address
gi 161 Carey Road,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 ri vJ
❑Burial Date Cemetery or Crematory
March 27, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
O Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
:;:; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
'''f Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IS Address
1
gi
Permission is hereb granted to dispose of the human r- ains d-scribed above as indic ed. �,�p
Date Issued Registrar of Vital Statistics f i -J,� �/ - rr0-i
(signature)
District Number 5601 Place Glens Falls
r:
I certify that the remains of the decedent identified above wer- disposed of in accordance with this permit on:
W Date of Disposition SIM tt+i Place of Disposition f,�,0 C .t,rl,—
W (address)
CO
rt (section) (I number) S (grave number)
pName of Sexton or Person i Charge f Premises t ,i1I ..- ti,4 -
Z (please print)
W
Signature Title afitiFit
(over)
DOH-1555(02/2004)