Meissner, Donald # It,
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
r 0 Name First Middle Last Sex
�. Donald Meissner Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 2, 2014 88 War or Dates WWII
IPlace of Death Hospital, Institution or
City, Town or Village Queensbury Street Address The Stanton Nursing & Rehab Center
Manner of Death g Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
r,, Roslyn Socolof, MD
Address
152 Sherman Ave.Queensbury,NY 12804
'i Death Certificate Filed District Number Reger Number
City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
May 5, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
Z
and/or Address
t..: Hold
Cl)
0 Date Point of
NTransportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
° ra Permit Issued to Registration Number
. r Name of Funeral Home Regan Denny Stafford Funeral Home 01443
j1 Address
rrrr 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address I
s
:vh Permission is hereby granted to dispose of the human r
mm ins described_above as indicated.
j Date Issued S �� Registrar of Vital Statistics
a:1. (signature)
.
::r District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition S/7Ipf Place of Disposition ?fu(kJ e <
2 (address)
W:
U)
I (section) (lot nuer) (grave number)
pName of Sexton or Person in Charge f Premises ir,iR L tm
Z' � (please print)
W Signature lit'
it' Title Clielilliee
(over)
DOH-1555(02/2004)