Donahue, Jr. George NEW YORK STATE DEPARTMENT OF HEALTH f - 1 Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
George Edward Donahue LI,c- Male
Date of Death Age If Veteran of U.S.Ar ed Forces, C
05/02/201 t 77 War or Dates / — ��
H Place of Death 9'.. -- Hospital, Institution orb //Gr �' 1 c�s
City, Town or Village }cg t7(O7 Street Address Deceased'sResidence
//
w
O Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name '� Title
0 PAUL BACHMAN,
Address
3767 Main ST. Warrensburg, NY 12885
Death Certificate Filed DDistrict Number Register Number
City ow r Village / Q�U?/1• 5&54 ,-
❑Burial Date Ce etery e��ematory /o 4,
❑Entombment 05/04/2011 , //,- e 4.e'e....2 L. Z..c'7tu//O*-1 tsdv7
Address
ElCremation -'
tic„‹. ` ne Izo€-Fzr-I / AY/7
Date Place Removed
z ❑ Removal and/or Held
Q and/or Address
H Hold
Date Point of
a. ❑Transportation Shipment
fA by Common Destination
5 Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00134
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ili
0 Permission is hereby granted to dispose of the human remain described 4tov as ind' ated.
Date Issued 5-3e I + Registrar of Vital Statistics /l,C� �a'
(signature)
District Number 5(j5Lf Place r-I.G Y\
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition -G i( Place of Disposition ?IN V,I t-rfA,t u riu r_
W (address)
C,)
Ce (section) /4 (lot number • (grave number)
aName of Sexton or erson in Charg f Premises t I rls}c��r 'APO
W /� L ,� 1(p/ease print)
Signature L Title C 21r M hZi2,
(over)
DOH-1555 (02/2004)