Burnett, David t tr zzS-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David W. Burnett Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 16,2013 59 War or Dates
1 Place of Death Hospital, Institution or
,i City, Town or Village Queensbury Street Address 11 Andrew St
Manner of Death n Natural Cause n Accident n Homicide Suicide Undetermined Pending
Circumstances 'Investigation
Au Medical Certifier Name Title
Tim Murphy Coroner
Address
52 Haviland Ave,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury S1 o%'") Z./ 9
0 Burial Date Cemetery or Crematory
04-19-2013 Pine View
0 Entombment Address
0 Cremation Queensbury,NY
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
V)
O Date Point of
Wn Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
h- Remains are Shipped, If Other than Above
;g Address
41
4, Permission is hereby granted to dispose of the human r#mains described above indicated.
Date Issued _ y_Lr—;.e►%3 Registrar of Vital Statistics J _tv f' _ r
(signature)
District Number St9sc� Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition q- Z1-13 Place of Disposition J .QL , Gr-(p(No,
W (address)
re (section) . (lot number (grave number)
OName of Sexton or Per on in Charg of Premises <r,5 poi NO
Z please print)
W Signature , � _ Title C ivitot
(over)
DOH-1555(02/2004)