Simons, David Lee Z ZZ.
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
David Lee Simons Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/25/2021 73 Years War or Dates Vietnam
p,, Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 33 Byrne Avenue,Glens Falls,New York 12801
W• Manner of Death ❑ Undetermined ❑Pending X Natural Cause 1:1Accident Homicide Suicide
tU Circumstances Investigation
W Medical Certifier Name Title
O Gerard Abess MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 115
ElBurial Date Cemetery,Crematory or Facility Name
02/26/2021 Pine View Crematory
El Entombment Address
ElCremation Queensbury Town,New York
Donation
OZ Removal Date Place Removed
and/or and/or Held
H N Hold Address
0
O. Date Point of
Cl) 11 Transportation Shipment c
p by Common p C— r
Carrier Destination
El Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
• Address
CC
W
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/25/2021 Registrar of Vital Statistics 1l'pdertAufrew Cultic gkctranicalySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 0727_01p2/ Place of Disposition �! ,�J e (7.1-e i) Cry 14_
W
(address)
ILI
CC(I)
(section) `,� (lot number)/ (grave number)
O Name of Sexton or Person in Charge of Premi s ��/M� �+/
Z _ (please print)
W Signature e Title 01907(
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# w.