David, Abraham J Jr. qtS—
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Abraham J.David Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/04/2022 91 Years War or Dates Air Force
�... Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
Q Manner of Death EI Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending
VCircumstances Investigation
QW Medical Certifier Name Title
Jennifer Donovan DO
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 90
Burial Date Cemetery,Crematory or Facility Name
06/07/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
Hold Address
N
0
I- Date Point of
V1❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
— Remains are Shipped,If Other than Above
,2 Address
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/07/2022 Registrar of Vital Statistics Caroline)fi(began[e Barber(E(ectronicallySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
4✓i'�
Z Date of Disposition 61$r ZZ Place of Disposition t u
address/
W
N
CC (section) (lot numbe (grave number)
0 Name of Sexton or Person in Charg Premises dpi L, -01 AA I1
Z lease print)
UJ Signature Title Cp&MK
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# .