Milne II, Donald . „ " ( 3(0
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald A Milne,II Male
? Date of Death Age If Veteran of U.S. Armed Forces,
� August 29, 2015 77 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 25 Fitzgerald Rd.
ig Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
g Medical Certifier Name Title
.51 Ageel A. Galonni,MD
Address
102 Park Street,Glens Falls,NY 12801
Death ' e Filed q District Number Register Number
_ Cit o nor Ilage , v4)v 5661 13
Date Cemeteryor Crematory
E Burial
September 2, 2015 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
F_ Hold
Cl)
Q Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
l(::. Remains are Shipped, If Other than Above
Address
gi
Permission is hereby granted to dispose of the human re in dOseribe• •� indi ed.
Date Issued 7-3\- \s Registrar of Vital Statistics l0 ,A,l.0
(signature)
'''f District Number 5(�5✓I Place 4p,,,,,� .4...ad cD1. 4-,LA ____y.
I certify that the remains of the decedent identified above re disposed of in accord 1 this permit on:
Z
W Date of Disposition R/3115- Place of Disposition r Or4i_-
2 (address)
W
Cl)
d' (section) A _(lot number)( (grave number)
pName of Sexton or Person in Charge of Premises Ghi<< J
W d. lease print)
Signature 4 Title (a4 t
(over)
DOH-1555(02/2004)