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White Jr., David Willard NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David Willard White Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 03/15/2023 73 Years War or Dates 1969-1975 Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death El Natural Cause DAccident Homicide Suicide Undetermined riPending W0 Circumstances Investigation W Medical Certifier Name Title O Marcille Labban MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 146 Burial Date Cemetery,Crematory or Facility Name 03/17/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation ZO❑Removal Date Place Removed - and/or and/or Held - Hold Address 0 O. Date Point of to❑Transportation Shipment p by Common Carrier Destination ODisinterment Date Cemetery Address Reinterment Date Cemetery Address 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 1— Remains are Shipped,If Other than Above 2 Address W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/17/2023 Registrar of Vital Statistics Megan Not-in(Electronically Signed) (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 Date of Disposition 3 17 a 1 21 Place of Disposition , IL r� (address) W (section) (lot numb (grave number) 8 Name of Sexton or Person in Charge o mises "`"{N (please print) Z J W Signature Title frirA41 HT'7 DOH-1555(07/18)p 1 of 2 16807 I 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# -