Towers, David NEW YORK STATE DEPARTMENT OF HEALTI i I (./ S.
'J
Vital Records Section ~ ' Burial - Transit Permit
Name First Middle Last Sex
David H Towers Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/1 2012 83 years War or Dates
#- Place of teat Hospital, Institution or
5 City, To Street Address
Glens F Clens Ils Hospital
Manner t Natural Cause Accident Homicide Suicide n e rmined Pending
III Circumstances Investigation
ill Medical Certifier Name Title
i
AddieE'mn Davidowitz M D
100 Park St Glens Falls, N Y 12801
iMi Death Certificate Filed District Number Register Number
City, Tow �ate Cemetery or Crematory
;; OEntombment Address09I20/2012 Pine View Crematorium
a❑Cremation
Quee.nsbur,
12804
Date Place Removed
Z Removal and/or Held
❑and/or
i Address
VIHold
0 Date Point of
Transportation Shipment
L" by Common Destination
Carrier
iii
El Disinterment Date Cemetery Address
O Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home, Inc- 00448
Address
11 7 Sherman Ave. Corinth NY 12822
Name of Funeral Firm Making Disposition or to Whom
14. Remains are Shipped, If Other than Above
Address
111
fl" Permission is hereby granted to dispose of the human remains d ibed aJbOve ndicated.
Date Issued 0g/19/7017 Registrar of Vital Statistics 1 � G�
(signature)
District Number Place
5601 Glens Falls
I ceI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k '(
til Date of Disposition `I(Ut((L Place of Disposition f,LUre U 644 r Ite—
a (address)
LU
ta
IX (section) AtcL_ r(lot num (grave number)
Name of Sexton or Prson in Chge of Premises `)""~
j (please print)
Signature Title Cti "l4-�L
(over)
DOH-1555 (02/2004)