McDonnell, Daniel b Ogg
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
F+.` Daniel F. McDonnell Male
Date of Death Age If Veteran of U.S. Armed Forces,
P September 21, 2016 73 War or Dates 1964-1966
s`s Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 1 Knight Lane
Manner of Death ❑X Natural Cause n Accident ❑Homicide n Suicide EiUndetermined 1-1 Pending
Circumstances Investigation
Medical Certifier Name Title
Paul Bachman MD
"` Address
268 Darrowsville Rd.Chestertown,NY 12817
Death Certificate Filed District Number Register Number
'£ City, Town or Village Lake George
❑Burial Date Cemetery or Crematory
09/23/2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ "—I Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N Ti Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:? > Permit Issued to Registration Number
, `` Name of Funeral Home Regan DennyStafford Funeral Home 01443
*:;.' Address
53 Quaker Road, Queensbury,NY 12804
`%.: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
%%a Permission is hereby granted to dispose of the human re ains described abov as indicated.
f 1) /-t
' Date Issued 9 f 23/�0 f So Registrar of Vital Statistics �p p
-, (signature)
District Number ��(� Place U i\I P_ o ] La ke G-ec r Qe t\J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition '1/7(e'j(; Place of Disposition MitePti ,,j (r- uau*..
Waddress)
CO
re (section) h (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises 74,dote' "tpil.
tZ (please print)
Signature 4 "LoriTitle ( (Z
(over)
DOH-1555(02/2004)