Dickinson, David Timothy (111—F)—
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David Timothy Diddnson Male
Date of Death Age If Veteran of U.S.Armed Forces,
10)05/2022 67 Years Waror Dates
i— Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 40 Twin Channels Road,Queensbury Town,New York 12804
E Mannerof Death 1:1 Natural Cause ❑AccidentHomicide OSuicide riUndetermined ❑Pending
UJ
0 Circumstances Investigation
WMedical Certifier Name Title
C Gerard Abess MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town foueensbury District Number Register Number
Cit E,Town orVillar 5657 144
Burial Date Cemetery,Crematory or Facility Name Vie
w Pine Crematory
Entombment Address
Cremation Queensbuty Town,New York
Donation
0❑Removal Date Place Removed
F and/or and/or Held
at Hold Address
2 Date Point of
(130Tran sportation
p by Common Shipment
Carrier Destination
disinterment
Date Cemetery Address
Date Cemetery Address
pReinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Otherthan Above
5 Address
1:1C
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/07/2022 Registrar of Vital Statistics CarOCme.?!rl�sgvr Bareer(Efectstmrca*Srgtrsd)
/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:
WDate of Disposition /C--Z'Z,_ Place of Disposition e 4e t/.'e �('.( t Lr'
2 (address/
W
N Q (section/ /! amber) (grave number)
j
8 Name of Sexton or Person in Charge 27"
/arma�� L UC)C'
Z (please print)
lidSignature //
/' Title [ f&3— —tG's—
DOH 1555(07/18)p 1 of 2
rp ..I ,,. P: '-., �'t
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# i' , p t, .