Kahn, David Edward 171
NEWYORKSTATE DEPARTMENT OF HEALTH I LF Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David Edward Kahn Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/08/2022 63 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
SManner of Death EI Natural Cause DAccident El Homicide DSuicide Undetermined ❑Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
0 Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
Cit ,Town or Village
g 5601 310
Burial Date Cemetery,Crematory or Facility Name
Addre2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Don ation
ORemoval Date Place Removed
F and/or and/or Held
N Hold Address
0
d. Date Point of
U)❑Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Re interment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
CC
la
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06109/2022 Registrar of Vital Statistics 5flsganNo4ra(EGctroxicaQ Sigxi4
(signature)
District Number 5601 Place 'may Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on;
WDate of Disposition 61i I aPlace of Disposition 'I rtedl�- e p('y�-
2 (address)
la
Ncc (section) d Nu[numbed (grave numbed
SName of Sexton or Person in Charge of Pr mises f'A "'� 4 tf
Z lease print)
IJJ Signature l� ,,, ,, Title
DOH 1555(07/18)pi of 2
7 .
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#