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NEW YORK STATE DEPARTMENT OF HEALTH /�,c--
Vital Records Section Burial - Transit Permit
., Name First Middle Last Sex
Donald E. Higley Male
:- Date of Death Age If Veteran of U.S. Armed Forces,
April 4, 2011 86 War or Dates WWII
' Place of Death Hospital, Institution or
Z City, Town or Village Lake George 1 Street Address 23 Jay Rd.
ci Manner of Death I XI Natural Cause I i Accident Homicide n Suicide 1 Undetermined Pending
US Circumstances Investigation
LI
ut Medical Certifier Name Title
g ChrChristopher D.Hoy Dr.
Address
102 Park St,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 9
❑Burial Date Cemetery or Crematory
April 6, 2011 Pine View Crematorium
❑Entombment Address
ll Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
N
0 Date Point of
O.
N Transportation Shipment
p by Common Destination
Carrier
(Disinterment Date ' Cemetery Address
Reinterment Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Sullivan Minahan & Potter 01675
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
k * Remains are Shipped, If Other than Above
5; Address
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Permission is hereby granted to dispose of the human r m 'ns described a ove as indicated.
Date Issued 4 l Co 6,0. Registrar of Vital Statistics
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition LI-1 •-i( Place of Disposition [,r,V4A0) CUM1oriii .
2 (address)
COIll
p1r (section) 7 (lot number) (grave number)
Name of Sexton or Per on in Charge f Premises C s-},, r ,],Ivl,�fl
Z , l (please print)
W Signature / Title CPLW)jj-l�-
(over)
DOH-1555(02/2004)