Cook, David W Jr. PERMIT MUST ACCO11PANY REMAINS TO DESTINATION
LF 936
FORM BT-1,12/2010
STATE OF NEW HAMPSHIRE 1.BURIAL PERMIT NO
BURIAL TRANSIT PERMIT 2.CITY OR TOWN
3.DECEDENTS NAME(First,Middle,Last) 4.SEX 5.DATE OF DEATH(Month,Day,Year)
DAVID W COOK JR MALE NOVEMBER 14,2023
6.AGE 7.DATE OF BIRTH(Month,Day,Year) 8.CITY,TOWN,OR LOCATION OF DEATH 9.COUNTY OF DEATH
34 Years AUGUST 26,1989 CHARLESTOWN SULLIVAN
10.METHOD OF DISPOSITION(1.Burial 2.Temp.Entombment 3.Cremation 4.Donation.54plausoleum 6.OtherZ CODE: 3
11.PLACE OF DISPOSITION(Name of cemetery,crematory or other place) PINEVIEW CREMATORY
12.LOCATION (City/Town,State) QUEENSBURY,NY
13.DATE OF DISPOSITION(Refer to 19a) NOVEMBER 22,2023
14.IF ENTOMBED(OR CREMATED)PLACE OF FINAL BURIAL
15.LOCATION OF FINAL DISPOSITION(City/Town,State) .. .
A CERTIFICATE OF DEATH,HAVING BEEN FLED AS REQUIRED BY THE LAS OF THS STATE,PERMISswh S HERM biVEN TO:
16.FUNERAL DIRECTOR CHELSEA A GRAVES 17.N.H.LIC.NUM ONLY 1088
18.NAME AND LOCATION OF FACILITY(City/Town,State) BENNETT FUNERAL HOME,CONCORD,NH
19.COUNTER SIGNED AGENT(City Board of Heath/Sub-Register if app.) 20.CITY/TOWN 21.DATE ISSUED(Month,Day,Year)
CHELSEA A GRAVES CHARLESTOWN NOVEMBER 17,2023
CEMETERY OR STORAGE VAULT AUTHORITY SHALL FILL OUT SPACE BELOW WHEN APPLICABLE
22.IF STORED,BODY WAS PLACED IN(Name of Storage Vault) 23.DATE STORED(Month,Day,Year) 24.CITY/TOWN,STATE
25.SIGNATURE OF SEXTON OR PERSON IN CHARGE OF STORAGE VAULT 26.DATE ISSUED(Month,Day,Year)
CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SPACE BELOW
27.TYPE OF DISPOSITION(Cremated,buried,etc.) 28.DATE OF DISPOSITION 29.NAME AND LOCATION OF CEMETERY OR VAULT
r'����� (Month,Day,Year)
if"Z -zvZ 3 P'it/6' t/;e9,4,2 er r(-4e r /
30.SECTION 31.GRAVE NO. 32.SIGNATURE OF SEXTON PERSON I CHARGE
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This permit,after beingsigned bythe Sexton orperson in charge(or byh �ral Director where there is no Sexton)must be forwarded within six days
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to the clerk of the town in which the disposition takes place.
Public Health Law Sec. 4145(2b) s
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Receipt
Human remainsof delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#