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King, David lawrence .� JQ",) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David Lawrence King Male Date of Death Age If Veteran of U.S.Armed Forces, 11/27/2021 82 Years War or Dates H Place of Death Hospital,Institution or ZCity,Town or Village Queensbury Town Street Address 22 Gentry Lane,Queensbury Town, New York 12804 pManner of Death © Natural Cause ❑Accident ❑ Homicide ❑Suicide Undetermined Pending U Circumstances Investigation G Medical Certifier Name Title Jennifer Stratton MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 230 ▪Burial Date Cemetery,Crematory or Facility Name 12/01/2021 Pine View Crematory El Entombment Address ElCremation Queensbury Town,New York ▪Donation o ElRemoval Date Place Removed and/or and/or Held N Hold Address 0 LL 1-1 Date Point of Cl) ❑Transportation p by Common Shipment 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 H Remains are Shipped,If Other than Above Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/01/2021 Registrar of Vital Statistics Caroline x(fegarde Barber(ECectronica1TySigned) (signature) District Number 5657 Place Queensbury, 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 4.-3 Zori Place of Disposition ,Je 2 (address) W CC (section) / (lot number) J (grave number) a st- O Name of Sexton or Person in Charge of Premises 7vi'�� ��do�J Z (please print) W Signature T� f Title - DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 1 1 Receipt Human remains of T delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#