Warren, David NEW YORK STATE DEPARTMENT OF HEALTH #6132-
Vital Records Section Burial - Transit Permit
`••• Name First Middle Last Sex
rr David Barton Warren Male
Date of Death Age If Veteran of U.S. Armed Forces,
::* July 4, 2014 85 War or Dates World War II
Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 5 Cramer Point Road
Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined I Pending
Circumstances Investigation
Medical Certifier Name Title
Christopher D.Hoy
Address
: 161 Carey Road, Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
15 City, Town or Village Lake George 5651 9
❑Burial Date Cemetery or Crematory
July 8, 2014 Pine View Crematorium
❑Entombment Address
❑X Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
Hold
0 Date Point of
N I 1 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
°:: � Address
i,; . •53 Quaker Road, Queensbury, NY 12804
:: Name of Funeral Firm Making Disposition or to Whom
i`` Remains are Shipped, If Other than Above
Address
' : Permission is hereby granted to dispose of the human remains described above as indicated.
sr
.Y.em Date Issued 1 "' b t T Registrar of Vital Statistics
signs ure) /
District Number 5651 Place Lake George
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ')-II-14 Place of Disposition ?,rt.t11.,,� Ci_tor-
2 (address)
W
co
iY (section) I _ (lot numWi) (grave number)
pName of Sexton or Pers in Charge of Premises r3Il
Z` (please print)
ul Signature 4 Title CP'1'/0T j
(over)
DOH-1555(02/2004)