Whalen, David Bruce NEW YORK STATE DEPARTMENT OF HEALT . 4.0
H
Bureau of Vital Records = Burial - Transit Permit
Name First Middle `m Last Sex
David Bruce Whalen Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/26/2022 62 Years War or Dates Marine Corp
1— Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 24A Sandhill Drive,Moreau Town,New York 12803
ILI
p Manner of Death El Natural Cause Accident EI Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G John Lukaszewicz MD
Address
101 Ridge Street 2,Glens Falls,New York 12801
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 49
HBurial Date Cemetery,Crematory or Facility Name
08/27/2022 Pine View Crematory
Entombment Address
Cremation Oueensbury,New York
Donation
ZZ aRemoval Date Place Removed
and/or and/or Held
i Hold Address
N
0
a Date Point of
fA❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Funeral Service 01444
Address
94 Saratoga Ave,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/26/2022 Registrar of Vital Statistics Leeann ffcCa6e(E(ectronicallySigned)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition g-4-7f)-fr Place of Disposition yi,t' (/,jV ( #1 1 4]c(
!JJ (ddress)
W
CC CC (section) (lot number) (grave number)
T
aName of Sexton or Person in Charge of Premises I Le Nei S�,V arc,S
Z (please print)
W Signature Title C C
DOH-1555 lo7/t8)p t of 2
I '32. rJ1.'.`:"t
Public Health Law Sec. 4145(2b)
Receipt r .
Human remains of ' delivered on , 20 ,
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#