Myers, David D. .. . _:, It //C..
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David D.Myers Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/21/2020 84 Years War or Dates
ZZ Place of Death Hospital,Institution or
ILIJ
City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
p Manner of Death Ei Natural Cause 0 Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending
GW Circumstances Investigation
Medical Certifier Name Title
Jennifer Donovan DO
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 197
❑Burial Date Cemetery,Crematory or Facility Name
10/26/2020 Pine View Crematory
El Entombment Address
X❑Cremation Queensbury,New York
ElDonation
OZEl Removal Date Place Removed
F and/or and/or Held
N Hold Address
0
O. Date Point of
f) Li Transportation
G by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped,If Other than Above
5 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/26/2020 Registrar of Vital Statistics Carolrnex/gari Barb-ergkctronicallySigned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
4,...._
Date of Disposition ID!7 ,//0 Place of Disposition '/
Ili
2 address)
W
R)
Q (section) (lot numbgr--- (grave number)
gName of Sexton or Person in Char f Premises �..J ^�ft
Z (p ase print/
IL Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on • , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#