Wilkes, David Clarence 0.2..*
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NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David Clarence Wilkes Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/31/2022 55 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death
1=1Natu rat Cause ❑Accident El Homicide ESuicide ❑Undetermined ❑Pending
W
C.) Circumstances Investigation
WW Medical Certifier Name Title
0 Mardlle Labban MD
Address
100 Park St,Glens Falls,New York 12801
DeEath Certificate Filed City Of Glens FaNs District Number Register Number
City,Town or Village 5601 189 —
Burial Date Cemetery,Crematory or Facility Name
04/01/2022 Pine View Crematory
EntombmentAddress
EICremation Queensbury Town,New York
DDonation
ZZ Removal Date Place Removed
0 Eland/or and/or Held
N Hold Address
0
O. Date Point of
Cl)ETransportation
a by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
5 Address
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W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/01/2022 Registrar of Vital Statistics Megan✓�olingYectron S0e9
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
Z Date of Disposition 5XZ-Z0%2... Place of Disposition pi ;oe ('i e,,,j C rc1,i4„
W
a (addrescl
W
U)
Q (section) lot nu er) (grave number)
gName of Sexton or Person in Cha a of Premiss �mv.4C" �ol2(
Z , ,j_(please print)
W Signature // .. Title i'Ver-aL7`cl
DOH 1555(o7h8)p 1 of?
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i ' E 5 b -k 4
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#