Congdon, David J ftz01
NEW YORK STATE DEPARTMENT OF HEALTH *+
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
David J.Congdon Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/22/2022 73 Years War or Dates 1969-1971
Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death Natural Cause Accident Homicide ESuicide EUndetermined ❑Pending
U -- Circumstances Investigation
US b Medical Certifier Name Title
Numan Rashid MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,TownorVillage i 4501 182
Burial Date Cemetery,Crematory or Facility Name
03/23/2022 Pineview Crematorium
Entombment Address
ECremation Queensbury Town,New York
Donation
QEl Removal Date Place Removed
and/or and/or Held
F-- Hold Address
CA
11. Date Point of
■Transportation
by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Date Cemetery Address
III Reinterment
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
1.. Remains are Shipped,If Other than Above
Address
it
#lt
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/23/2022 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1—
WDate of Disposition 3I jt((ZZ Place of Disposition �',it--
2 (address)
WCO
re (section) A
(lot number)c (grave number)
gName of Sexton or Person in Charge ofPre ises f‘S 1 . 4Iit
Z (‘):aseprint) /�
Signature JCS- Title L�f/ �4(�1�
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of : T ' /`"° delivered on 20
Pine View Cemetery Representing the funeral home named/,u bxiiiq�p etit
Official Funeral Directors Reg.or License# "