St.Germain, David James , • #
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David James St.Germain Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/29/2023 56 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Aviation Road,Queensbury Town, New York 12804
ILI
p Manner of Death ❑Natural Cause Accident Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
O Paul Bachman MD
Address
3767 Main Street,Warrensburg Town, New York 12885
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 17
Burial Date Cemetery,Crematory or Facility Name
02/02/2023 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
8❑Removal Date Place Removed
and/or and/or Held
N Hold Address
O
Date Point of
N Transportation
S by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
2 Address
CC
uJ
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/02/2023 Registrar of Vital Statistics Caroline HYclegar1e Barber(ECectronicalty 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
W Date of Disposition c;?_y Z!?Z 5 Place of Disposition ?;,J e etAl C fy•ri t
2 (address)
W
(section) (lot num rl (grave number)
's
g Name of Sexton or Person in Charge of Premises ✓4 1 ZVN Lt.9( 7
d
(please print)
W Signature / Title r7� w
DOH-1555(07/18)p t of 2
'? 66 E
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#