McDonald, Timothy NEW YORK STATE DEPARTMENT OF HEALTH ? 3gt)
Vital Records Section Burial - Transit Permit
-
Name First Middle Last I Sex
Timothy Michael McDonald I Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 18, 2015 52 War or Dates
Place of Death Hospital, Institution or
Wei City, Town or Village Glens Fallsrj
Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑Undetermined ❑ Pending
Circumstances Investigation
vAi k Medical Certifier Name Title
Frances Bollin•er MD,
Address
IV 161 Care Rd Queensbu , NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village 25 1
❑Burial Date Cemetery or Crematory
May 22, 2015 Pine View Crematorium
• ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
eg Date Place Removed
AI❑ Removal and/or Held
and/or Address
Hold
71 Date Point of
IL'illiTransportation Shipment
t .1 by Common Destination
Carrier
'44
• ❑ Disinterment Date Cemetery Address
14,1
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
*4
mee Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
N• ame of Funeral Firm Making Disposition or to Whom
R• emains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
:1 Date Issued 5/ 20 ' (,5 Registrar of Vital Statistics f yJOA.c, , L'J
(signat
District Number rj 6O 1 6�S 1 'S ) g '
Place
- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
thl Date of Disposition 05/22/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
bil
H (section) I, (lot number (grave number)
• Name of Sexton or Person in Charge of Premises
// ,/ please print)
te itrovtal
Signature �L /`t--� Title
(over)
DOH-1555 (02/2004)