DeRosier, Donald (Oa
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
4....",
Name First Middle Last Sex Male
Donald J. DeRosier
Date of Death I A_ge If Veteran of U.S. Armed Forces
74 10/3/2011 ,
i War or Dates No
- , Place of Death I Hospital, Institution or
, City, xmotomoula Glens Falls
Manner of Death
72(i
I Street Address Glens Falls Hospital
Natural Cause 0 Accident ED Homicide OSuicide
El Undetermined ri Pending
Circumstances 'investigation
Medical Certifier Name Title
9 Evangelos Pallis MD
Address
1 Glens Falls, NY ,
Death Certificate Filed EbTsTrict Number I, Reg7nunrer
City, 15010001Klge Glens Falls 5601
• : Date Cemetery or Crematory
0 Burial i 10/5/2011 Pine View Crematory
Address
Li Cremation! Queensbury,NY
„.
- {1 Date Place Removed
gri Removal ; and/or Held
and/or Address
Hold
Date Point of
ui El Transportation : Shipment
a by Common Destination
* : Carrier
r-i Date ! Cemetery Address
.i.i. L.]Disinterment
! .
.-.
.,.H r--1 Date I Cemetery Address
j L. Reinterment
Permit Issued to ' Registration Number
:!
si Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church St., Lake Luzerne,NY 12846
.A.I. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
PA Permission is hereby ranted to dispose of the human remains des. ibe• ab ve icated.
' Date Issued /006-0W/ Registrar of Vital Statistics i' .":"
giI1 (signature)
District Number ..5-69V Place 'I•eb , /-;77.Z, /t-Y
.::. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i;.:01
Date of Disposition j --)-o--6011 Place of Disposition R oe ':Q‘,.) C -n ue -q.,-k or l'u yvi
(address)
ILI
(A
_(...g.cii.on) .1 (lot nymber) (grave number)Name of Sexton or Person in Charge of Premises itri O-1-4,/ ilr,.,(IR'IC
0
Z --------: (please print)/
Lii Signature • ' " L , Title C..r kigcLAs$51
DOH-1555 (10/89) p. 1 of 2 VS-61