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York, David G 4 .it to S NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex David G York Male Date of Death Age If Veteran of US.Armed Forces, 08/11/2023 77 Years War or Dates 1965-69 ZPlace of Death Hospital,Institution or pCity,Town or Village Stillwater Town Street Address 83 Luther Road,Stillwater Town,New York 12866 Manner of Death IZ Natural Cause ❑Accident Homicide Suicide Undetermined nPending tU ' 'Investigation Investigation al Medical Certifier Name Title 0 George Siniapkin MD Address 604 Palmer Avenue,Corinth Town,New York 12822 Death Certificate Filed Town Of Stillwater District Number Register Number City,Town or Village 4567 18 Burial Date Cemetery,Crematory or Facility Name 08/14/2023 Pineview Crematory Entombment _ Address ©Cremation Queensbury Town,New York ❑Donation 0❑Removal Date Place Removed p and/or and/or Held N Hold Address 0 d Date Point of N ElTransportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom f- Remains are Shipped,If Other than Above S Address fr a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/14/2023 Registrar of Vital Statistics Danielle Cowin(Electronically Signed) (signature) District Number 4567 Place Town Of Stillwater I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H W Date of Disposition 8(IS"(3 Place of Disposition �?�� /* ` 2 (address) W N S (sedion) h/(lot number) (grave number) Name of Sexton or Person in Charge of Premis rya 9 t)N U . /p!e se print) / Signature Title (tip DOH-1555(07/18)p t of 2 1 Public Health Law Sec. 4145(2b) i ,. 7211 Receipt 1 Human remains of delivered on , 20 I Pine View Cemetery Representing-the funeral hone named on burial permit Official Funeral Directors Reg.or License#