Weeks Jr, Donald NEW YORK STATE DEPARTMENT OF HEALTH '1-i3
Vital Records Section # t Burial - Transit Permit
Name First Middle Last Sex
Donald Varnum Weeks,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
▪ June 25,2015 70 War or Dates Army
Place of Death Hospital, Institution or
City, Town or Village Glens Falls,NY Street Address Glens Falls Hospital
Q Manner of Death ❑X Natural Cause ❑Accident E Homicide El Suicide ❑Undetermined n Pending
1. Circumstances Investigation
�. Medical Certifier Name Title
Aqeel Gillani,MD
Address
yGlens Falls,NY
' Death Certificate Filed District Number Register Number
• City,Town or Village Glens Falls,NY 5601 3 2�
❑Burial Date Cemetery or Crematory
El Entombment June 26,2015 Pine View Crematory
Address
LI Cremation Queensbury, NY
Date Place Removed
ZG 1-7 Removal and/or Held
and/or Address
H Hold
Cl)
o Date Point of
N0 Transportation Shipment
aby Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
0 Permit Issued to Registration Number
r
:,;, Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
7.,
Address
407 Bay Road,Queensbury, NY 12804
t Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
; e
Address
,-,, Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 6 f 2$'/!5 Registrar of Vital Statistics
;// -1'`')CA-1-t‘--t ' '‘e-jf)-
(signatur
fr. District Number 5 j i Place 6 S c IN 5 w `,i
04 / j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ui Date of Disposition,-X.,--I Place of Disposition �'"i'nf'tJcf'w Cr-'►'-i CIO r t'c' si
(address)
W
co
(secti (lot number) (grave number)
ZName of Sexton or Pers in arge of Premises i A,, i 'u1i //e
W `—_ / (please print)/
Signature Title Cre,11A4ory 14,51
(over)
DOH-1555(02/2004)