Waters, David ff 322
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David L. Waters Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 16,2013 79 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
441
cs Manner of Deathwkir-`71Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined n Pending
Circumstances Investigation
u Medical Certifier Name n� S Title Pa-
Address
"''7C 5-f- a,5 fivii 11. Re fitter umber
Death Certificate Filed District Number g
City, Town or Village Queensbury S L r ! 0
❑Burial Date Cemetery or Crematory
June 4s,2013 Pine View Crematorium
El Entombment Address
ID Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ• ❑Removal and/or Held
and/or Address
H Hold
U)
Q Date Point of
N ❑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
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
Address
CG
tit
a' Permission is hereby granted to dispose of the human re ainsdescribed a ve as indicated.
Date Issued - 3 - 0, Registrar of Vital Statistics ` — Y
(signaturef
District Number 5�,,:,- ) Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z `C Ctir-c1-0(fives.
� Date of Disposition b��l�►3 Place of Disposition � ��
(address)
W
U)
re (section) (tot umber) i�(( (grave number)
00 Name of Sexton or Perso in Charge of P emises /1)t
��� ✓� -tMM1T
z (pl ase print)
W Title Cirhl°r'td
L
Signature
(over)
DOH-1555(02/2004)