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Davis, Edward F
19 # 1 N EW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Edward F Davis Male Date of Death Age If Veteran of U.S.Armed Forces, 02/05/2024 93 Years War or Dates E,.., Place of Death Hospital,Institution or Z City,Town or Village Fort Ann Village Street Address 80 Catherine Street, Fort Ann Village, New York 12827 `0 Manner of Death Z Natural Cause Accident ❑Homicide Ei Suicide []Undetermined Pending Circumstances Investigation 0 Medical Certifier Name Title Ci Robert Love MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed Village Of Fort Ann District Number Register Number City,Town or Village 5723 1 Burial Date Cemetery,Crematory or Facility Name ® 02/06/2024 Pineview Crematorium Entombment — Address ©Cremation Queensbury Town,New York ❑Donation Removal Date Place Removed 1. and/or and/or Held Hold Address 01 t4 Date Point of ta0Transportation by Common Shipment Carrier Destination I []Disinterment Date Cemetery Address Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom f. Remains are Shipped,If Other than Above a Address a W EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/06/2024 Registrar of Vital Statistics Miranda Herringshaw(Electronically Signed) (signature) District Number 5723 Place Village Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: .1— W Date of Disposition Z 14 119 Place of Disposition ra'n16413v(-.) (F,/hi�y,l�'>G.-� (address) W CC (section) (lot$umber . (grave number) Name of Sexton or Person in Charge of Premises �Aa. ft 2 (pa e print/ /� lam, Signature �� ‘-- Title 6 �'►� IZ� DOH-1555(07/18)p 1 of 2 1 - , 1_,7, ?3 Public Health Law Sec. 4145(2b) Receipt Human remains of '`' delivered on , 20 ___ee_Z , Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#