Bushey, Donald 33Z
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
r Name First Middle Last Sex
:Kli Donald Roy Bushey Male
r:,7§ Date of Death Age If Veteran of U.S. Armed Forces,
;.*: May 4,2015 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
.? Manner of Death X Natural Cause I I Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
J. Stratton Dr.
�� Address
; :.; 14 Manor Dr.,Queensbury,NY 12804
�,{:••: Death Certificate Filed District Number Register Number
.:; City, Town or Village Glens Falls 5601 2.. ,
❑Burial Date Cemetery or Crematory
May 6, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
/— Hold
(15
0 Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
rJ Permit Issued to Registration Number
;:' ': Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
V, Address
'.J 407 Bay Road, Queensbury, NY 12804
'# Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:'•:•,1 Permission is hereby granted to dispose of the human remains described above,tas indicated.
:Jti Date Issued 5 /;� /(5 Registrar of Vital Statistics � f�Z
:•
'r'r} (signature
�rr4 District Number Place
;�;, 5601 Glens Falls) Al y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Chits Place of Disposition -gaii„ C--.1%•--
2 (address)
W
CO
0 (section) (lot nutter) (grave number)
pName of Sexton or Person in Charge of Premises /L.f' .,
WZ %
A__.,--
(please print)
Signature Title �fNljt
(over)
DOH-1555(02/2004)