Carpentar, Danny R w-93(3
NEW YORKSTATE DEPARTMENT OF HEALTH fi Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Danny R.Carpenter Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/05/2021 74 Years War or Dates 1964-1979
Place of Death Hospital,Institution or
Z City,Town or Village Lake Luzerne Town Street Address 11 Ramsey Place, Lake Luzerne Town, New York 12846
W Manner of Death Undetermined Pending
W Natural Cause ❑Accident 0 Homicide ❑Suicide Li
U Circumstances Investigation
W Medical Certifier Name Title
0 Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Lake Luzerne 5656 15
❑Burial Date Cemetery,Crematory or Facility Name
11/05/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
N Hold Address
0
a Date Point of
(I) ❑Transportation
p by Common Shipment
Carrier Destination
0 Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
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
1— 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 11/05/2021 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:
� )
Z Date of Disposition /H/S r ZI Place of Disposition `I 'em1u`—
W
2 (address)
W
N (section) d
(lot number) c (grave number)
JT
Name of Sexton or Person in Charge Premises t`i
Z (pie a print)
W Signature Title ` 0 TV
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#