Ettline, David R il 100c
1.r
NEW YORKSTATE DEPARTMENT OF HEALTH le" Burial - Transit Permit
Bureau of Vital Records 4 ,
Name First Middle Last Sex
David R.Ettline Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/17/2022 78 Years War or Dates Army
i_ Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address 35 New Street,Saratoga Springs,New York 12866
ILI
a Manner of Death II Natural Cause Accident Homicide ESuicide r1Undetermined riPending
ILI
0 Circumstances Investigation
W Medical Certifier Name Title
CI Alice Kolasa MD
Address
445 New Karner Road,Colonie Town,New York 12205
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 746
H
Burial Date Cemetery,Crematory or Facility Name
12/20/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
EiDonation
❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
N❑Transportation
El- by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
j=IReinterment
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
S Address
Q
W
0 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/19/2022 Registrar of Vital Statistics Dillon Moran(ECectronicallySigned)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition IZ 121 112 Place of Disposition
�l_ ZI;(1----
2 (address)
W
CCCC (section) (lot number) (grave number)
8 Name of Sexton or Person in Charge of P miles al L.-- YlVti
(p/ se print)
uJ Signature Title (fiF.rnhrit
DOH-1555(07/18)p 1 of 2
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#