Wheeler, David R .0 # 533
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David R Wheeler Male
Date of Death Age If Veteran of U.S.Armed Forces,
•
07/05/2022 64 Years War or Dates
l` Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
p Manner of Death 0 Natural Cause Accident []Homicide []Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 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 106
EiBurial Date Cemetery,Crematory or Facility Name
07/06/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
F Hold Address
U)
0
a. Date Point of
Cl)❑Transportation
8by Common Shipment
Carrier Destination
o
Disinterment
Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
l— Remains are Shipped,If Other than Above
2 Address
CC
I LI
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/06/2022 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed)
(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:
z ��V /
W Date of Disposition 7 h I ZZ Place of Disposition t ` 1�'0•^�
2 (address)
W
NCC (section) .flot number) c (grave number)
gName of Sexton or Person in Charge of Premises l fug �^' "tt
Z Tease print) /+ RAC
W Signature /./ Title G(1•l�i/�M}Iv'�
DOH-1555(07/18)p t of 2
�' .� .ry a.
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home nanT t on burial permit
Official Funeral Directors Reg. or License#