Tracy, David .11
NEW YORK STATE DEPARTMENT OF HEALTH ' S Gvi
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David H Tracy Male
Date of Death (1 al 31 17Q 3 Age If Veteran of U.S.Armed Forces,
• 70 War or Dates NO
Z Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death ®Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Robert W. Sponzo MD
Q Address
102 Park Street Glens Falls New York 12801
Death Certificate Filed District Nur er \ ReginNger
City,Town or Village Glens Falls `
❑Burial Date Cemetery or Crematory
June 4, 2013 Pine View Crematory
❑Entombment Address
®Cremation Town of Queensbury-
Date Place Removed
0 ❑Removal and/or Held
and/or Address
I" Hold
11) Date Point of
0 ❑Transportation Shipment
CL by Common Destination
0 Carrier
- Date Cemetery Address
0 ❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
F= Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
a
W Address
O.
Permission is fhereby granted to dispose of the human remains described above as indicated.
Date Issued 6 I i-i i i 3 Registrar of Vital Statistics
UOCA�s gnatu e)��l���District Number s G 0 t Place C; LiZA., -S rCA \ \ S 1 N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
2
w (g/c Date of Disposition 1i5 Place of Disposition ° address C�dof to
to ( )
to
le
0 (section) (lot numb (�rave number)
O Name of Sexton or Person in Charge of Premi s fo JPane
Z (pleas print)
W
Signature —s _ Title C rµ'i476C
(over)
DOH-1555 (02/2004)