Wall, Donna 4.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
q [
Name First Middle Last Sex
Donna L. Wall Female
Date of Death Ape If Veteran of U.S.Armed Forces,
April 20,2006 59 War or Dates NO
Place of Death Hospital, Institution or
City, Town or Village City of Glens Falls Street Address Glens Falls Hospital
W Manner of Death X Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
to
la n Circumstances Investigation
a Medical Certifier Name Title
0 Aqeel Gillani MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 1 69
El Burial Date Cemetery or Crematory
4/21/2006 Pine View Crematory
❑ Entombment Address
❑X Cremation Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
H Hold
N Date Point of
d ❑ Transportation Shipment
V) by Common Destination
G Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Sullivan Minahan&Potter 01734
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
aPermission is hereby granted to dispose of the human remains described above as indicated.
Date Issued `') ) Z if 0 6 Registrar of Vital Statistics R O A e-c,tiz n /cAA-)
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— f
iZ Date of Disposition LI/a I /G , Place of Disposition Pill VtttJ C1'tin.S- orsi ..-(address)
w
N (section) (lot_number) (grave number)
W I
O Name of Sexton or Person in Charge of Premises ().C LJ Seh0it-
Z /i i c (please print)
W Signature C A l Title C re r c f e f
DOH-1555 (02/2004) (over)