Donohue, Robert 4 NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
r;; Name First Middle Last Sex
Robert Kenneth Donohue Male
rr Date of Death Age If Veteran of U.S. Armed Forces,
rr October 14, 2015 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
1) . NC1L'I C SiCAIi1, ��i � I�.
::j Address
:f i U( f�Ci r I-' S F r ee t L� Ic n F C I I , N \I i S U.�
:i:: Death Certificate Filed District dumber Register Number
: City, Town or Village S�G'l Soco2
El Burial 1 Date Cemetery or Crematory
October 16, 2015 i Pine View Cemetery
❑Entombment Address
❑Cremation , Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
O.
Transportation Shipment
a by Common Destination
Carrier
•
Disinterment Date Cemetery Address
ReintermentI
Date Cemetery Address
::1 Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
:'::r Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tg
Permission is hereby granted to dispose of the human remains desc ibed a ve i dicated.
Date Issued /0 /,S Ze7/1' Registrar of Vital Statistics 'eh! r -
(signature)
District Number 6----6,c)i Place O7-P-w /l�s' f /t_/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1 0/1 6/1 5 Place of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
W
y Horicon 43A 1
0 (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises Connie L. Goedert
'Z (please print)
Signature )li. ),rt-,c1 Title Cemetery Superintendent
J (over)
DOH-1555(02/2004)