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Matthews, Donald Paul
NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donald Paul Matthews Male Date of Death Age If Veteran of U.S.Armed Forces, 01/16/2020 70 Years War or Dates Place of Death Hospital,Institution or ,Z City,Town or Village Queensbury Town Street Address 46 Lyon Court,Queensbury Town,New York 12804 p Mannerof Death Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation U W Medical Certifier Name Title William Borgos MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 10 ©Burial Date Cemetery,Crematory or Facility Name 01/23/2020 Pine View Cemetery Entombment Address ❑Cremation Queensbury,New York Donation Z Removal Date Place Removed O and/or and/or Held F N Hold Address O IL Date Point of N ❑Transportation Shipment by Common Carrier Destination Date Cemetery Address Disinterment Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom t= Remains are Shipped,If Other than Above :E Address IIE W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/20/2020 Registrar of Vital Statistics Carorirex�garde Bar6er�--kctrnrticaf Sr rrterl� (sigiature) 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: F Z Date of Disposition i- 01� p1D� Place of Disposition / c pd W (address) T j W (section) (lot number/ (grave number) 8 Name of Sexto qr Person in Charge of Premises (Please print) W Signature Title i DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 010362 Receipt delivered otF `0 Human remains of -a t ,� , 20 __e.> Mjo Pine View Ce etelry Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# I _, ti MATTHEWS Owner QJ) LUCILLE C TVU THEWS Plot Address 46 Lyon Court Queensbury NY 12804 Horicon Phone # Lot # 518-745-0817 41 C Deed # Date 4156 1 /17/2020 Cost Foundation Y - N $650.00 Location HORICON: West: Road East: Vacant North:Vacant South: Classi Remarks Record of Interments 1 Donald P. Matthews Died 1 /1 6/2020 6 2 7 3 8 4 9 5 10 t � s � nc MATTHEWS NAME Donald P. Matthews Age: 70 Lot Owner: Lucille C. Matthews Lot# 41C Horicon Grave# 1 Case: Concrete Died: Interred: 1 /16/2020 1 /23/2020 Funeral Home: Singleton,Sullivan Potter Funeral Home Cemetery: Pine View Cemetery