Reynolds, Donna t 1, .}�
NEW YORK STATE DEPARTMENT OF HEALTH 7T 111
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donna J. Reynolds Female
Date of Death Age If Veteran of U.S. Armed Forces,
12 / 19 / 2016 54 War or Dates
j-- Place of Death Hospital, Institution or
fCity, Town or Village Saratoga Springs Street Address Mary's Haven
a Manner of Death E Natural Cause E Accident Homicide _Suicide � Undetermined 0 Pending
Ili Circumstances Investigation
til Medical Certifier Name Title
0 Eric A. Pillemer MD
Address
•
102 Park St #3, Glens Falls, NY 12801
i Death Certificate Filed District Number Li i 5O I Register Number -
City, Town or Village Saratoga Springs —1
DBurial Date Cemetery or Crematory
12 / 20 / 2016 Pine View Crematory
i I Entombment Address
Iii;Pir]Cremation Queensbury, NY
Date Place Removed
In o Removal and/or Held
and/or Address
f=" Hold
IV Date Point of
Q Transportation Shipment
C by Common Destination
Carrier
ft
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iiiiiii Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
ikig Address
402 Maple Ave. , Saratoga Sp. , NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
III
"` Permission is hereb granted to dispose of the human rema' cri d alt/t&k1
y indicat .
Date Issued ( Registrar of Vital Statistics "
(signature)
ti District Number LiaA Place Saratoga Springs , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition I LI tt(IL Place of Disposition gru,V,:,./ `' c'f .,
2 (address)
lid
fI
IC (section) /• (lot numbe (grave number)
C. Name of Sexton or Person ip Charge o Premises C�-� �.
► a (please print) •
i Signature Title ��+ m
(over)
DOH-1555 (02/2004)