Spotswood Jr., Francis W. NEW YORK STATE DEPARTMENT OF HEALTH ., Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Francis W.Spotswood Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/08/2021 82 Years War or Dates Korean
F. Place of Death Hospital,Institution or
Z City,Town or Village Day Town Street Address 32 Old Day Center Road, Day Town, New York 12835
p▪ Manner of Death Natural Cause Li Accident ❑Homicide 1=1 Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Scott Munro MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Hadley 4554
riBurial Date Cemetery,Crematory or Facility Name
04/09/2021 Pine View Crematory
Entombment Address
EiCremation Queensbury Town,New York
El Donation
0 Z Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d Date Point of
w ❑Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
ElDisinterment
Date Cemetery Address
ElReinterment
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
g Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/09/2021 Registrar of Vital Statistics Carol Vaillancourt(Electronically Signed)
(signature)
District Number 4554 Place Hadley, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H i I
W Date of Disposition �0 a 2/ Place of Disposition �;.-1 ( V e /"
) ` IF
l/
ress
CC CC (section) (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises 'f (ple(aaseeprint
Z
W Signature Title (�� '�
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt 1i
Human remains of delivered on , 20
. i
a. t
Pine View Cemetery Representing the funeral home named on,burialspermit
Official Funeral Directors Reg.or License# ' a I