Nelson, David NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David _ E. Nelson Male
R. Date of Death • Age If Veteran of U.S. Armed Forces,
07/jj3/212 71 years War or Dates 1958 1962
iLIF Place o ea Hospital, Institution or
Z City, Tow iI,•; Street Address
t Mx) c-:XX CIens F Clcn I s H s itol
Manner o ea h ,!_ Natural Cause Accident Homicide Suicide �nde?ePmined ❑Pending
iti Circumstances Investigation
IIjt Medical Certifier Name Title
i
Address I Bachman Coroncr
Warrensburg Health Center, Warensburg, NY
Death Certificate Filed District Number Register Number
City, Tow5tAA ill tile.
AxX Glons Falls 5601 351
52['Buriala e Cemetery or Crematory
ID Entombment Address 07/25/2012 Pine View Cemetery
Mii.XISr/pmation Queensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
and/or Address •
LT Hold
0 Date Point of
Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton- Mc Dermott Funeral Home, Inc. 00134
Mi Address
q Pine Street Chestertown N Y 12817
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
Cr
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/75/0017 Registrar of Vital Statistics LOC, & -,_Q k.A. ,A..A/
(signature)
District Number 5601 Place Glens Fails N (a l0'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k ILI Date of Disposition '1-2(,-12 Place of Disposition f 4/t ti, 6.4e .
2 (address)
Ui
tr (section) (lot num)er) (grave number)
A
0 Name of Sexton or Person in Charge of Premises rye c
(please print)
1 Signature /142Title C4l`Nli}to(L.
(over)
•
DOH-1555 (02/2004)