Martell, Donald i . 1 , 6 0 Z,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Y:i: Name First Middle Last Sex
o.:}' Donald G. Martell Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 14, 2015 80 War or Dates
j.. Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs
iStreet Address Mary's Haven
. ' Manner of Death X Natural Cause I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
is John Stoutenburg MD
r Address
102 Park St.Glens Falls,NY 12801
: Death Certificate Filed District Number Registerer Number
r{: City, Town or Village Saratoga Spri ngS, NY J�� `02___
❑Burial Date Cemetery or Crematory
August 17, 2015 Pine View Crematorium
❑Entombment Address
E1 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F Hold
ta
0 Date Point of
NI I Transportation Shipment
3 by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
r:; Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
g: Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I'°' Remains are Shipped, If Other than Above
Address
Permission is h reb granted to dispose of the human re ins es ibe as indic ted.
::'0.": Date Issued $ `—] i� Registrar of Vital Statistics
:.: (signature)
v:
rr : District Number 4rt) Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4J i ii - Place of Disposition 24tki ChMliek,•-r'
2 ` (address)
W
CO
0 (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises Af 4i PAov 3 r '
Z � V (please print)
W ��GL Title /Vw1n ,.
Signature
(over)
DOH-1555(02/2004)