McClatchey, Donald NEW YORK STATE DEPARTMENT OF HEALT-t
Vital Records Section Burial - TransitPermit
Name First Middle Last i Sex
U ; Donald F. McClatchey j Male
Date of Death Age f If Veteran of U.S. Armed Forces,
K' 06/20/2014 1 80 War or Dates Other
_-.-p- Place of Death 1 Hospital, Institution or /L� �!i-���� if,
City,Town or Village Chestertown 1 Street Address Deceased's Residence
Manner of Death Natural Cause ID Accident [3 Homicide❑ Suicide El Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
0
�- Daniel C. Larson, 7
Address
.,_::5,:,-_ State rte 9 Chestertown, NY 12817
37 De- • •---.ficate Filed District Numbg{ I Registef Number
6,J (�
Cit Tow or Village s-'
Date or Cre t 70 Burial 06/23/2014 �-E�� / tip ��v2
❑Entombment Address 6,Jc 1 6ii.e.,,,,,,,,, ,icy. A Zf;a]Cremation ` "l 9 �C� l d
Date 1 Place Removed
I17 Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
'' Carrier
k0 r
Disinterment
Date Cemetery Address
►= , Reinterment Date Cemetery Address
, Permit Issued to Registration Number
4-'0 Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
_ Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
„ Remains are Shipped, If Other than Above
Address
tiO Permission is hereby granted to dispose of the human m 'ns es,cribe e as ndicated
�o �y�
Date Issued / Registrar of Vital Statistics -
(sign ture)
District Number 6-6,„..5,� Place �Ay�'
I certify that the remains of the d cedent identified above wer isposed of in accor ce with this permit on:
Date of Disposition C Z --/ Place of Disposition 04, Vxt....--
,,-
'I (address)
(section) t number) (grave number)
/ 5.,,,t_ 440
��.` Name of Sext r n in Charge of Premises
�,, � '��'� Y"ase x" t)
Signature "� Title t)-re • `
(over)
DOH-1555(02/2004)