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Kipp Jr., David W NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David W Kipp Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 11/20/2021 74 Years War or Dates 1964-1968 Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause Accident El HomicideEl Suicide ❑Undetermined 0 Pending Circumstances Investigation W Medical Certifier Name Title CI Marvin Davidowitz MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 528 ❑Burial Date Cemetery,Crematory or Facility Name 11/29/2021 Pine View Crematorium Entombment Address X❑Cremation Queensbury Town,New York ElDonation Z Removal Date Place Removed and/or and/or Held H Hold Address ill O Date Point of co ❑Transportation by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls, New York 12839 Name of Funeral Firm Making Disposition or to Whom F. Remains are Shipped,If Other than Above g Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/23/2021 Registrar of Vital Statistics Robert Andrew Curtis('ECectronicaCCySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: qq W Date of Disposition /7.3 '_ ,)l Place of Disposition �e (.% eui 2 (address) W EC (section) (lot number) (grave number) GName of Sexton or Person in Charge of Premises I6v l� °�� Z (please print) W Signature , % ` � Title of -1-zn,.- DOH-1555(07/18)p 1 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#