Nevens, Donald NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald Alson Nevens Male
ri Date of Death Age If Veteran of U.S.Armed Forces,
06/25/2017 90 Years War or Dates 1944-1946
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
611 Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined 1-1❑Pending
Circumstances Investigation
Medical Certifier Name Title
Mathew Varughese DO
Address
.-:, 100 Park St,Glens Falls,New York 12801
7 Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 347
❑Burial Date Cemetery or Crematory
06/27/2017 Pine View Crematorium
44"❑Entombment Address
ElCremation Queensbury Town, New York
p
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
_ ❑Transportation Shipment
by Common Destination
Carrier
°,❑Disinterment
Date Cemetery Address
#, ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
",i: Address
w
Permission is hereby granted to dispose of the human remains described above as indicated.
re
Date Issued 06/27/2017 Registrar of Vital Statistics /?,6ertACurtis FCectronicaaySigned
(signature)
- District Number 5601 Place Glens Falls, New York
Nt
.''' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r.
ill Date of Disposition Pin'rI Place of Disposition fikU,� /rN4ag---
W (address)
(/)
ilk (section) fillot number) c , q (grave number)
to Name of Sexton or Person in Charge of remises `44- jkwi 1
z // (plefse print)
W •Signature /1 Title triort 2.
(over)
DOH-1555 (02/2004)