VanWagner, Donna NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permit
': Name First Middle Last Sex
Donna VanWagner Female
Date of Death Age If Veteran of U.S. Armed Forces,
09 / 13 / 2016 74 War or Dates
t Place of Death Hospital, Institution or
Z City, Town or Village Saratoga Springs Street Address 10 Michael Dr.
Uj
0 Manner of Death®Natural Cause E Accident Homicide E Suicide ❑Undetermined �Pending
W. Circumstances Investigation
la Medical Certifier Name Title
Q David M. Mastrianni MD
Address
3 Care Ln #300, Saratoga Springs, NY 12866
Death Certificate Filed District Number J' I Register Number,,,,
City, Town or Village Saratoga Springs `'j
`'0Burial Date Cemetery or Crematory
09 / 15 / 2016 Pine View Crematory
kiii nEntombment Address
Cremation Queensbury, NY
' Date Place Removed
.a❑Removal and/or Held
and/or Address
12
Hold
VP Date Point of
ifi Q Transportation Shipment
• by Common Destination
Carrier
Q Disinterment Date Cemetery Address
gi
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave. , Saratoga Sp. , NY 12866
Name of Funeral Firm Making Disposition or to Whom
kJ Remains are Shipped, If Other than Above
• Address
tle
"` Permission is hereby granted to dispose of the human remai rib ab ' dicated
im Date Issued q ILI Ili Registrar of Vital Statistics •
I I
(signature)
Vi
District Number 4501 Place Saratoga Springs , New York
#- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
111 Date of Disposition q/ftJ , Place of Disposition gnct«�, ( r,t s.
(address)
til
ta
te (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of 4Premises 'h's (t1- S@NAlfr
Zlease print) •
Signature , Title C.NfF.-
(over)
DOH-1555 (02/2004)