Donohue, William NEW YORK STATE DEPARTMENT OF HEALTH ?
Vital Records Section Burial - Transit Permit
m.
zF Name First Middle Last Sex
" William Francis Donohue Male
Ai. Date of Death Age If Veteran of U.S. Armed Forces,
o April 10, 2015 67 War or Dates
-" Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 11 Western Ave
Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Paul F. Bachman, ME
- Address
Warrensburg, NY 12885
Death Certificate Filed District Number Register Number Q.
City, Town or Village Glens Falls .C9 1 ��0
1 0 Burial Date Cemetery or Crematory
May 13, 2015 Pine View Crematory
• ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
nTransportation Shipment
by Common Destination
Carrier
lir ❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
• Permit Issued to Registration Number
• Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereb granted to dispose of the human Cnains des ' ed above s indicated.
To Date Issued i3 Registrar of Vital Statistics U 1'--)-2 �'
��„ gn tune) >1.,
District Number ,4Y? I Place
ilk i
I certify that the remains of the decedent identified above were disposed of in accordance with this p rmit on:
Date of Disposition 05/13/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
., of number)
(section) (grave number)
; ° Name of Sexton or Person in Charge of Premises
ft '3ha -
AI 2 (plefase
r Signature Title alEmag-
(over)
DOH-1555 (02/2004)