McComb, David e 1111 It 613)
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David McComb Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 4, 2014 65 War or Dates
▪ Place of Death Hospital, Institution or
• City, Town or Village Bolton Landing Street Address 24 Anchorage Rd.
g Manner of Death X Natural Cause I I Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
gi Eric Pillemer MD
Address
Glens Falls Hospital, 100 Park St, Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
.. City, Town or Village Bolton Landing 5650 7
❑Burial Date Cemetery or Crematory
July 7, 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
H Hold
N
O Date Point of
coTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
iiili Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
iiiii Name of Funeral Firm Making Disposition or to Whom
1' Remains are Shipped, If Other than Above
Address
. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 `- --)9 Registrar of Vital Statistics
•:.: "4-4. (signature)
District Number 5650 Place Bolton Landing
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1—1-ly Place of Disposition /„MUD,., �rri•-c-OrW—
W (address)
U)
(section) (lot nu r) (grave number)
a Name of Sexton or Person i Charge of Premises i,� en .
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W
Signature Title C120 t'1T1
(over)
DOH-1555(02/2004)