Loading...
Davis Terry Wade j .75 It 3 Li L NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Terry Wade Davis Male Date of Death Age If Veteran of U.S.Armed Forces, 04/13/2023 70 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 202 Fifth Street ext,Queensbury Town,New York 12804 0 Manner of Death a Natural Cause ❑Accident ❑Homicide ESuicide FlUndetermined riPending W Circumstances Investigation W Medical Certifier Name Title O Anne Evans DO Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 59 Burial Date Cemetery,Crematory or Facility Name 04/14/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation ZO❑Removal Date Place Removed and/or and/or Held F Hold Address N 0 Date Point of (I)❑Transportation Shipment p by Common Carrier Destination O Disinterment Date Cemetery Address Ell 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 a Address Q W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/14/2023 Registrar of Vital Statistics Caroline?fiCclegarde Barber(E(ectronica((ySigned) (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: H Z Date of Disposition t-)(I$)7, Place of Disposition T'-��J. 111 (address) W CA CC (section/ (lot numbe (grave number) 0 ��p•},L IIT 0 Name of Sexton or Person in Charge, miles f/p/ease print) Z l y W Signature Title 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#