Loading...
Mayotte, David C � rk _ 667 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David C.Mayotte Male Date of Death Age If Veteran of U.S.Armed Forces, 08/09/2021 69 Years War or Dates �.. Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital pManner of Death © Natural Cause Accident El Homicide 0 Suicide El Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title Hung Nguyen MD Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 433 0 Burial Date Cemetery,Crematory or Facility Name 08/11/2021 Pine View Crematory ❑Entombment Address Cremation Queensbury Town,New York 0 Donation Z Removal Date Place Removed O El and/or Held — and/or Hold Address O O.. Date Point of U) Li Transportation Shipment by Common — Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom - Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/11/2021 Registrar of Vital Statistics John Taut Eranck(ECectronicaCCySigned) (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 1 J lZ+'Li Place of Disposition at U'-- L,J d IL.-- LU (address) W N (section) /j (lot number) (grave number) d it Name of Sexton or Person in Charge of Pre es //{1 11� � _S�^��'� Z (please print) 11J Signature Title DOH-1555(07/18)p t of 2 ..507t2 Public Health Law Sec. 4145(2b) Receipt 111 Human remains of delivered on , 20 1 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#