Large, David NEW YORK STATE DEPARTMENT OF HEALTH ' ' ' 4 sz 8
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David Edward Large Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/03/2013 72 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 1 3 Sage Lane (Fort Edward)
Manner of Death El Natural Cause El Accident El Homicide Ei Suicide Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Robert W. Sponzo MD
Address
Cancer Center 102 Park Street, Glens Falls,NY 12801
Death Certificate Filed District Number ti Register Number
City,Town or Village Moreau `�
❑Burial Date 0 9/0 5/2 01 3 Cemetery or Crematory
Pineview Crematory
0 Entombment
,P Cremation Address 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
71 Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
EiDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral HomeMB Kilmer Funeral Home 01 078
Address
136 Main Street, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remain described above as dicated.,
Date Issued 60,0,5 Registrar of Vital Statistics
signature)
District Number 4 6,2 Place of
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1103 Place of Disposition `f acna )i ui
(address)
(section) lot number) (grave number)
Name of Sexton or Person in Charge f Premises
pfli
( ease print)
Signature Title Ca MV OL
(over)
DOH-1555(02/2004)