McDonough, Sr. Robert NEW YORK STATE DEPARTMENT OF I-�EAI TH . S
Vital Records Section I Burial - Transit Permit
Name First ,PIiddle Last Sex
Robert W. McDonough, Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
it October 14,2011 92 War or Dates World War II
. Place of Death Hospital, Institution or
1 City, Town or Village Queensbury _ Street Address Stanton Nursing & Rehab Centre
litManner of Death X Natural Cause Accideht Homicide Suicide n Undetermined Pending
till Circumstances Investigation
g Medical Certifier Name Title
? Roslyn Socolof Dr.
Address
• :"42 Gurney Lane,Queensbury,NY 12804
Death Certificate Filed District Number Register mber
®_.1 City, Town or Village Queensbury 5657 1 00
❑Burial Date Cemetery or Crematory
❑Entombment October 17,2011 Pine View Crematorium
Address
0 Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sullivan-Minahan& Potter 01646
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
" Remains are Shipped, If Other than Above
N: Address
l"
• '; Permission is hereby granted to dispose of the human re rn ins described) a ve as indicated.
a=. Date Issued I o-1,4-,�,,, Registrar of Vital Statistics Vim` �_�
• :i] (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 10 I ci hi Place of Disposition ?am to etin,41orwv+.
Ill
(address)
CO
W (section) lot number) (grave number)
pName of Sexton or Pers in Charge of remises 4ti si 1 r- ,Q'�^aLt
Z g (please print)
W Signature Ab")..--.. Title (Z..M►�l
(over)
DOH-1555(02/2004)