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Fountaine, David Martin irf- NEW YORKSTATE DEPARTMENT OF HEALTH I Burial Transit Permit Bureau of Vital Records Name First Middle Last Sex David Martin Fountaine Male Date of Death Age If Veteran of U.S.Armed Forces, 01/25/2024 77 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 11.1 Manner of Death El Natural Cause Accident Ei Homicide Suicide Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title a Matthew Loftus PA 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 51 L Burial Date Cemetery,Crematory or Facility Name 01/30/2024 Pine View Cemetery Entombment — Address Cremation Queensbury,New York Donation Z❑Removal Date Place Removed E and/or and/or Held Hold Address ❑Transportation Date Point of 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 P ,° Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above IAddress 11' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/26/2024 Registrar of Vital Statistics Megan.No(in(ECectronicallySigned) (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:Date of Disposition `?pc)• a Place of Disposition I (Juc Kj c i..LJ C t)�CeJib ram/ Ili`� /02t3 0 / ILI (address) J / III 14Rlecn Ty' 1,0 cc (section) ) �' (lot number) (grave number) 8 Name of Sexton or Person in Charge of Pre ' s i)n n i r �i:CJC-r 4- 4.4 (please print) W Signature4 Title <lxr i n17UI C�)-6- DOH-1555(07/18)p 1 of 2 17418 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 P$e View Cemetery Representing the funeral home named©n burial permit Official Funeral Directors Reg.or License# GAZETOSLF �\ Lot No. 29 Address 50 Grant Ave . , Glens Falls , NY 12801 Section No. Dwner Plot Horicon 4"( - 3/ /- 31 L2 1 J r /-,5)U / Date 2/9/96 Apprrix 30 Superficial ft. Location Bounded on North by Road , South by Vacant & Svolos ,west by Vacant , East by Path . Corner Posts Remarks Deed No. (and changes) 2725 Payment Record Paid in Full 2/9/96 ( $7 0 0 . 0 0 ) Record of Internments ti George James Gazetos 11/18/02 Y _ C Angela Gazetis 1/8/04 N S >c X�c- `s- 7 .7`/ 8 LA) Form No. 01 FOUNTAINS (Th NAME David M. Fountain Age: 77 Lot Owner: GeorgeJ. & Angela Gazetos Lot# Horicon 29 Grave# 6 Case: Concrete Died: 1 .2 5.2 4 Interred: 1 .3 0.2 4 Funeral Home: Regan Denny Stafford FH Cemetery: Pine View