Hempstead, Donald Michael # �3r
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald Michael Hempstead Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/06/2019 59 Years War or Dates
II.— Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 72 Alpine Ave,Queensbury Town,New York 12804
W Mannerof Death Undetermined Pending
� � Natural Cause �Accident �Homicide �Suicide � � g
V Circumstances Investigation
W Medical Certifier Name Title
Ranen Chakraborty DO
Address
1783 Route 9,Clifton Park Town,New York 12065
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 162
Burial Date Cemetery,Crematory or Facility Name
11/08/2019 Pine View Crematory
Entombment Address
x Cremation Queensbury Town,New York
Donation
z Removal Date Place Removed
and/or and/or Held
to Hold Address
O
IL Date Point of
U) ❑Transportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
IF— Remains are Shipped,If Other than Above
g Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/07/2019 Registrar of Vital Statistics Carohnexldegarae Bar6er(EYectronicalySigned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 5 Place of Disposition ,, °�✓ ���
g (address)
W
N (section/ (lot number/ (grave number)
Q
aName of Sexton or Person in Charge of Premises t j �`�
/ Q /pl se print/Z
W Signature /...t Title
DO H-1555(07/18)p t of 2
' w
Public Health Law Sec. 4145(2b) 01, 3060
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ",