Gale Jr, Donald NEW YORK STATE DEPARTMENT OF HEALTH 010
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
: Donald Gale,Jr Male
'r Date of Death Age If Veteran of U.S. Armed Forces,
November 12, 2014 61 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury, NY Street Address 35 Eisenhower Ave
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Tim Murphy,Coroner
:ii::ii:
Address
Glens Falls,NY
;rrr Death Certificate Filed District Number Register Number
_ City, Town or Village Queensbury,NY 5657 ISID
❑Burial Date Cemetery or Crematory
II Entombment November 17, 2014 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
� Hold
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O Date Point of
yI I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:a
ris: Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
: Address
53 Quaker Road, Queensbury,NY 12804
:a� Name of Funeral Firm Making Disposition or to Whom
#+' Remains are Shipped, If Other than Above
SAddress
gi
▪ Permission is hereby granted to dispose of the huma re ins , - -`i1id • , •ve•dicated.
;: Date Issued i,(-1, 1-14 Registrar of Vital Statistics +
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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 ff��
111
Date of Disposition 11 A$ii Place of Disposition trite V c...i Lim4p{',v...,
W (address)
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CC (section) (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises 4-61,,,,.., ,at
IZ (please print)
Signature �� L. Title Cis L-
(over)
DOH-1555(02/2004)