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Kingsley, Donald J. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donald J.Kingsley Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 01/25/2020 90 Years War or Dates F. Place of Death Hospital,Institution or WCity,Town or Village Ticonderoga Town Street Address Heritage Commons Residential Health Care p Mannerof Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title Kristin Mack DO Address 1019 Wicker St,Ticonderoga Town,New York 12883 Death Certificate Filed District Number Register Number City,Town or Village Ticonderoga 1564 6 ❑Burial Date Cemetery,Crematory or Facility Name 01/28/2020 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation 0 ❑Removal Date Place Removed and/or and/or Held ~N Hold Address O IL Date Poi nt of N Transportation Shipment p by Common Carrier Destination ❑Disinterment Date Cemetery Address ❑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 orto Whom f.. Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/28/2020 Registrar of Vital Statistics 7onya M Thompson(Efectronicaffy Signed (signature) District Number 1564 Place Ticonderoga, 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 11700 Place of Disposition V.., . 40( \ 12 W (address) W N (section/ (iotnumber) (grave number) M It Name of Sexton or Person in Charge of Premises ('t {''""t (Pleade print) W Signature Title DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 013234 Receipt Human remains of delivered on , 20 ' Pine View Cemetery y Representing the funeral home named on burialTermit Official Funeral Directors Reg.or License#