Keech, Donald Robert Mr)
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald Robert Keech Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/20/2020 87 Years War or Dates 1956-1958
F. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
WW Manner of Death
Natural Cause Accident 0 Homicide 0 Suicide E]Undetermined El Pending
C.) Circumstances Investigation
Q Medical Certifier Name Title
Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 482
0 Burial Date Cemetery,Crematory or Facility Name
10/21/2020 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
11 Donation
Removal Date Place Removed
and/or and/or Held
Hold Address
CO
0
Cl) Li Transportation Date Point of
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
C
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/21/2020 Registrar of Vital Statistics Ruben Andrew Curtis(ECectronically Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W I
Date of Disposition VI ZL JZO Place of Disposition �
2 (a dress)
W
0 (section) Sot num (grave number)
0 Name of Sexton or Person in Char•:.f Premises ` 4Leaseprint)
t
,
W Signature Title i( iV''/
DOH-1555(07/18)p 1 of 2
I
Public Health Law Sec. 4145(2b) 4 ;a 141
s
Receipt
Human remains of =- --, ,-, delivered on ,/6 I ` ,�� , 20 'r
.✓ ti
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# / V ir.
1