Donohue, William NEW YORK STATE DEPARTMENT OF HEALTH 703
Vital Records Section ` x Burial - Transit Permit
Name First Middle Last Sex
William L Donohue Male
: Date of Death Age If Veteran of U.S. Armed Forces,
April 14, 2012 76 War or Dates
Place of Death Hospital, Institution or
Z`' City, Town or Village Glens Falls Street Address Glens Falls Hospital
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• Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
m" Circumstances Investigation
? Medical Certifier Name Title
P.a Michael Adams,MD
Address
] 1448 Route 9, South Glens Falls,NY 12803
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 / y�9
❑Burial Date Cemetery or Crematory
April 18, 2012 Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury, NY 12804 _
Date + Place Removed
Z Removal and/or Held
and/or Address
F Hold
N
O Date Point of
coTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
ka:v41 Permit Issued to Registration Number
:: Name of Funeral Home Regan & Denny Funeral Home 01444
Address
°'1 94 Saratoga Avenue, South Glens Falls,NY 12803
: Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Ei Address
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Permission is hereby granted to dispose of the human remains descr eed�abo e as icated.
�y/Date Issued 7/2�+/z- Registrar of Vital Statistics .� :c� 1`
p;®1 (signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition ((/I 6Ij2 Place of Disposition P,IUtew C i rtum.
W (address)
co
O (section) (lot num r) (grave number)
QName of Sexton or Person in Charg of Premises Al r JtMr1(>�'
'Z 1.1
//4pL
(please print)
Signature � Title ('W,I plea
(over)
DOH-1555(02/2004)