Golden, Ronald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
r:;r Name First Middle Last Sex
Ronald Edward Golden Male
°r1 Date of Death Age If Veteran of U.S. Armed Forces,
j March 3, 2014 80 War or Dates
'r Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 47 Minnesota Avenue
Manner of Death l Xl Natural Cause [ l Accident l 'Homicide Suicide n Undetermined ]Pending
MA Circumstances Investigation
Medical Certifier Name Title
Christopher Messitt DO
Address
is': 135 North Rd,Wilton,NY 12831
Death Certificate Filed District Number Register Number
i:;:; City, Town or Village Queensbury 5657 �1::))
❑Burial Date Cemetery or Crematory
March 5, 2014 Pine View Crematorium
❑Entombment Address
III Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
u) [ l Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
l Reinterment Date Cemetery Address
Ivs
:;l Permit Issued to Registration Number
E:K: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
E . Address
::: 407 Bay Road,Queensbury,NY 12804
'� Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
: ::, Address
.,{ Permission is hereby granted to dispose of the human e ains described above as indicated.
.. y C � CAS 1LA _
;:�: Date Issued ����I Registrar of Vital Statistics
i`:`° (signature)
::: District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition A 1'1114 Place of Disposition ZeUk,..1 C.„440f;,,_
W (address)
fY
(section) (lot num (grave number)
4 Name of Sexton or Person in Char a of Premises to wIr
Z (p ase print)
W Signature Title Cu Mr
4— T
(over)
DOH-1555(02/2004)