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Fisher, David A
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David A.Fisher Male Date of Death Age If Veteran of U.S.Armed Forces, 06/06/2021 75 Years War or Dates 1964-1967 Place of Death Hospital,Institution or City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing US p Manner of Death © 0 Undetermined E Pending �J Natural Cause Accident Homicide. Suicide Circumstances Investigation w Medical Certifier Name Title Leonard Gelman MD Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville 5756 i 48 ❑Burial Date Cemetery,Crematory or Facility Name 06/08/2021 Pineview Crematorium 0 Entombment Address X❑Cremation Queensbury Town,New York ElDonation ❑Removal Date Place Removed and/or and/or Held tl Hold Address 0❑Transportation Date Point of Q by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address tt #fit ` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/07/2021 Registrar of Vital Statistics Jenny Linda M Martelle(Electronically Signed) (signature) District Number 5756 Place Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t%' Date of Disposition 41R I tt Place of Disposition - Ine LL i to-_ ` (address) Ws LL (section) (lo umber) (grave number) Name of Sexton or Person in Charge of Premi s th A lr —S ^'Ai 2, (please pun iii Signature Title CW1�C i DOH-1555(07/18)p t of 2 1 Public Health Law Sec. 4145(2b) 14 8 4 5 Receipt • ---- _ ,--<,... ,.) - i Human remains of 1-,'./'1 1 .,•-: 1:--,/,_.. .=-,/--,;‘,i delivered on 7- 1 . , 20 :2'. I i . , . ,-/-. „- '-• /f -- --- ,-- ; ' . //i ' '- ..:.---,, '-- . , ,....., Pine View Cemetery Representing the funeral home named op burial permit Official Funeral Directors Reg.or License# i ...- --/',' /