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Swota, David John NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David John Swota Male Date of Death Age If Veteran of U.S.Armed Forces, 09/05/2021 73 Years War or Dates i_ Place of Death Hospital,Institution or ZCity,Town or Village Northumberland Town Street Address 4 French Meadow,Northumberland Town,New York 12831 p Manner of Death © Natural Cause D Accident Homicide 1=1 Suicide El Undetermined El Pending W Circumstances Investigation W Medical Certifier Name Title 0 Eric Schnakenberg MD Address 711 Troy-Schenectady Road,Latham Hamlet, New York 12211-00000 Death Certificate Filed District Number Register Number City,Town or Village Northumberland Town 4563 9 ▪Burial Date Cemetery,Crematory or Facility Name 09/10/2021 Pine View Crematory Li Entombment Address O Cremation Queensbury Town,New York ▪Donation O• ElRemoval Date Place Removed and/or and/or Held H Hold Address 0 Q. Date Point of Cl) Li Transportation Shipment Q by Common Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address Q LU O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/10/2021 Registrar of Vital Statistics Denise D Murphy(ECectronica(ty Signed) (signature) District Number 4563 Place Northumberland Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition 9����( Place of Disposition -79ja e , � (�� ,.! Crent t,-ip (addressA o f CC (section) tt (lot number) (grave number) 0 Name of Sexton or Person in Charge o Premises �H�iNtra�I �` LJCI)C1 (please print) W Signature r/✓"' Title �}-�- DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt \ Human remains of ••• delivered on • s 4 -' , 20 `c ., •••••:-\•$ -- A A r - — Pine View Cemetery Representing the funeral home named fon burial permit Official Funeral Directors Reg.or License#