Waters, David Clarence Sr. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David Clarence Waters Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/24/2022 83 Years War or Dates 1958-1960
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
G Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 495
Burial Date Cemetery,Crematory or Facility Name
09/27/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
O
Date Point of
to Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F.. Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/26/2022 Registrar of Vital Statistics Megan Wolin(ECectronica1TySigned)
(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:
Z
W Date of Disposition 9frc1 I Z Z Place of Disposition 4"--/"6.c��,. :(am.---
(address)
III
N°C (section) ,� (lot number) (grave number)
gName of Sexton or Person in Charge of Pre (pi se print)
W Signature l Title i K��mlqVZ
DOH-1555(07/18)p t of 2
a
Public Health Law Sec. 4145(2b) �� i 'I �' �� L.` 1 - i
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# `