Killian Sr, Donald I lli F zsy
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald F. Killian,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 15,2014 64 War or Dates Vietnam
. Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address 292 Golf Course Road
WManner of Death I XI Natural Cause I Accident I 'Homicide Suicide Undetermined Pending
Circumstances Investigation
uujj Medical Certifier Name Title
0 John E.Lukaszewicz MD
Address
84 Broad St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number 2
City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
Entombment April 17,2014 Pine View Crematory
Address
XI Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
—I— Hold
rn
0 Date Point of
N I I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
(Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 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
2 Address
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Permission is hereby granted to dispose of the human rem ins described� above�y/ as in c;
indicat d.
Date Issued 1/ �'/�
/ Registrar of Vital Statistics ` jG'C,L,'t(Y-�
(signature) "
District Number 5660 Place Warrensburg,NY
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z C�..
4..4
W Date of Disposition k+11�0� Place of Disposition 4Or,o�.'
W (address)
CO
0 (section) (tot number (grave number)
Z Name of Sexton or Person in Charge of Premises
fstt,
W I(p!ease print)
Signature 4....
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Title F✓OW�t ,iOl?,
(over)
DOH-1555(02/2004)