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Tubbs, David M • . . c ye NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David M.Tubbs Male Date of Death Age If Veteran of U.S.Armed Forces, 07/21/2021 49 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Lake Luzerne Town Street Address 308 Potash Road, Lake Luzerne Town, New York 12846 W Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ri Undetermined Pending Circumstances Investigation • Medical Certifier Name Title CI Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Lake Luzerne 5656 11 ❑Burial Date Cemetery,Crematory or Facility Name 07/23/2021 Pine View Crematory ❑Entombment Address lCremation Queensbury Town,Warren,New York ❑Donation o Removal Date Place Removed and/or and/or Held H' Hold Address 0 O. Date Point of to 1-1 Transportation Q by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 F. Remains are Shipped,If Other than Above 1- Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/22/2021 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed) (signature) District Number 5656 Place Lake Luzerne, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition 7113171 Place of Disposition •Ri,�� ,:[of+w� 2 (address) W N CC (section) 17 (lot number) (grave number) � AM a Name of Sexton or Person in Charge of emises r' �' Z (ple e print) W 4160 Title w7ror Signature DOH-1555(07/18)p t of 2 6 Public Health Law Sec. 4145(26) - 0 14 9 6 Receipt Human remains of I delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#