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Williams, David E. NEW YORKSTATE DEPARTMENT OF HEALTH ` ,1 Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David E Williams Male Date of Death Age If Veteran of U.S.Armed Forces, 01/26/2021 80 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 44 Willowbrook Rd, Queensbury Town,New York 12804 `p Manner of Death © Natural Cause ❑Accident El Homicide ❑Suicide El UndeterminedPending Circumstances Investigation Medical Certifier Name Title G Thomas Kandora MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 35 ❑Burial Date Cemetery,Crematory or Facility Name 01/28/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation ❑Removal Date Place Removed and/or and/or Held F- Hold Address 0 - — a Date Point of (I) ❑Transportation Shipment 5 by Common Carrier Destination ❑Disinterment Date Cemetery Address El 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 F.. Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/28/2021 Registrar of Vital Statistics Caroline xfiCegarie Barfer(Electronically Signed) (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: ZIL W Date of Disposition 1 VI I Zj Place of Disposition R. ..., (address) W CO (section) (lot number) (grave number) c G Name of Sexton or Person in Charge of Pre ises �'�l' ""4l ft � (p! se print) W Signature Title fly DOH-1555(07/18)p 1 of 2 • 1_ Public Health Law Sec. 4145(2b) 314475 Receipt Human remains of delivered on , 20- Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# t ,