Walp, Donald ..i-.. i vrsm o I t%1 C uGrAK 1 MtN 1 Ur HEALTH 'Fr `'}
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald W. Walp Male
°! x Date of Death Age If Veteran of U.S. Armed Forces,
., January 11,2014 85 War or Dates
-' Place of Death Hospital, Institution or
City, Town or Village Johnsburg Street Address 92 Cleveland Road
Manner of Death XI Natural Cause Accident Homicide Suicide 1 Undetermined Pending
V,jCircumstances Investigation
Medical Certifier Name Title
0 Stephen Monn
F. :a Address
92 Broad Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
a City, Town or Village Johnsburg 5655 ..1
❑Burial Date Cemetery or Crematory
Entombment January 14,2014 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z l I Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
fijj 1 I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
(Reinterment Date Cemetery Address
_H Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
3 Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I.- Remains are Shipped, If Other than Above
:* Address
;la Permission is hereby granted to dispose of the hum r ains describ d above a indicated.
1 Date Issued I — i S- l Registrar of Vital Statistic L9 a ,
(sign re)
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ( /15-I1 j Place of Disposition gru,Uhu.r (.w.{Or,.av-
2 (address)
W
O (section) (lot number)r (grave number)
p Name of Sexton or Perso in Charge f Premises tyre lz J
lease print)
W Signature Title `dY
(over)
DOH-1555 (02/2004)