Wallace Sr, Donald 7-)'
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald E. Wallace,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 25,2014 86 War or Dates World War II
i... Place of Death Hospital, Institution or
`Z City, Town or Village Warrensburg l Street Address 43 James Street
p Manner of Death I XI Natural Cause 'Accident [ I Homicide Suicide I Undetermined [ (Pending
Lu Circumstances Investigation
w Medical Certifier Name Title
Paul Bachman
Address
IIIIIIN,Warrensburg,NY 12885
Death Certificate Filed ; District Number Register Number
City, Town or Village ThurmanWarrensburg 56595660 3
❑Burial Date Cemetery or Crematory
January 27,2014 Pine View Crematory
❑Entombment Address
Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z I !Removal and/or Held
O and/or Address
F Hold
co
O Date Point of
cn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
f Reinterment Date Cemetery Address
- -
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home l 00037
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
E Address
rY
W
a Permission is reb granted to dispose of the human al described above as indicated.
Date Issued _/ Registrar of Vital Stat. ics
(signature)
District Number 5660 Place Warrensburg
F-
tv I certify that the remains of the decedent identified above were disposed of inn accordance with this permit on:
r e-ctOJlw
Date of Disposition I/Q�i(i( Place of Disposition 'FOAL r/
(address)
co
fY
(section) % (lot numbs (grave number)
O _
p Name of Sexton or Per n in Char a of Premises ; t%Nal
(please print)
LU
Signature Title (A-rQYj
(over)
DOH-1555 (02/2004)