Cross, Doanld NEW YORK STATE DEPARTMENT OF HEALTH 3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
. .,, Donald L. Cross Male
' Date of Death Age If Veteran of U.S. Armed Forces,
x January 11, 2015 88 War or Dates VV4.5.`'�I�
r Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death rn
ELI Natural Cause 0 Accident 0 Homicide ❑ Suicide ❑ Undetermined 1-1❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Gary Scidmore,
Y
4- Address
1340 State Route 9 Lake George, NY 12845
Death Certificate Filed District Numl s. 1 Registember
• City, Town or Village Glens Falls
- ❑Burial Date Cemetery or Crematory
January 14, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
r Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
-, Carrier
-, � Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
123 Main St., Argyle NY 12809
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
h' Address
Permission is hereby granted to dispose of the human remains escribed above,as i icate .
- Date Issued Registrar of Vital Statistics /tp p_i--7 ` 7 Ci?. I
4 1 (signature)
District Number 6-?/7/ Place
i
Yr; I certify that the remains of the decedent identified above were disposed of in accorda a with this permit on:
Date of Disposition 01/14/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /� ,(lot number) (grave number)
g Name of Sexton or Person in Charge of Premises 641„1L SnA14r
(please print)
' t• Signature Title a {
(over)
DOH-1555 (02/2004)