McDonald, Wilbur G4/L4/LU14 GO: GO 101b('iLlZtS( L KEGAN & DENNY FUNEKA PAGE 01/01
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NEW YORK STATE DEPARTMENT OF HEALTH # 2 (P(-1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
NC
r Wilbur Leslie McDonald C Male
r'? Date of Death Age If Veteran of U.S. ArmedForces,
April 21, 2014 75 War or Dates
.., Place of Death Hospital, Institution or
z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause —Accident ['Homicide 1 'Suicide ❑Undetermined Ti Pending
'T Circumstances Investigation
cif` Medical Certifier Name Title
James North
e d. Address
r: 100 Broad St,Glens Falls,NY 12801
', i Death Certificate Filed District Number Register Number
;f5 City,Town or Village Glens Falls 5601 _20 2 —
:' n Burial Date Cemetery or Crematory
April 23, 201.4 Pine View Crematory
LI Entombment _..:.. _..
•. Address
:• :_QCremation Quaker Road, Queensbury,NY 12804
'::) _ Date Place Removed
1❑Removal and/or Held
' and/or Address
;W Hold
C UY
Date Point of
p ❑Transportation __ Shipment
; by Common Destination
Carrier
;?''i❑Disinterment Date Cemetery Address
:;❑Reinterment Date Cemetery Address
!Sigi Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
,S::cal Address
fry 407 Bay Road,Queensbury, NY 12804
a Name of Funeral Firm Making Disposition or to Whom
ii
:r$ Remains are Shipped. If Other than Above
Address
,. Permission is hereb granted to dispose of the human remains descrl ed aabov s i dJted.
;ti4 Date Issued D V2.00/`/ Registrar of Vital Statistics �'�--
.40 (signeture)
..le
District Number 5601 Place Glens Falls
,..W.
I certify that the remains of the decedent Identified above were disposed of in accordance with this permit on:
InDate of Disposition 4 h'i l Iy Place of Disposition -(l;Uki, top;...
2_ (address)
la
'' (section) lot number) (grave number)
�• �`
fl Name of Sexton or Person In Charge f Premises sip Seat*
.� (please print)
410 Signature t/r Title CiVErw4
(over)
DOH-1555(02/2004)