Mitchell, Donald A. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald A.Mitchell Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/18/2019 72 Years War or Dates
I.— Place of Death Hospital,Institution or
WCity,Town or Village Lake George Town Street Address 2913 State Route 9,Lake George Town,New York 12845
'p Mannerof Death ❑X Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
G John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Lake George 5651 8
❑Burial Date Cemetery,Crematory or Facility Name
12/20/2019 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
❑Donation
OZ ❑Removal Date Place Removed
and/or and/or Held
~N Hold Address
IL Date Point of
N ❑Transportation I
p by Common Shipment
Carrier Destination
I
Disinterment Date Cemetery Address I
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
a
Permission is hereby granted to dispose of the human remains described above as indicated. I
i
Date Issued 12/19/2019 Registrar of Vital Statistics Dwforaf 4 Fbley(ElearonicallrySr wed j
(signature/
District Number 5651 Place Lake George, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 11110 1)y Place of Disposition
W (address)
W
IM (section/ (lot number) (grave number/
0 Name of Sexton or Person in Charge of Premises s l st-'Olt
Z ��� (p! se print)
W Signature /✓ Title
DOH-1555(o7/18)p i of 2
I
Public Health Law Sec. 4145(2b) P
i
Receipt
Human remains of i r' delivered on i , 20
Pine View Cemetery Representing the funeMfhome named on burial permit
Official Funeral Directors Reg.or License# °`1`'
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