Fitzsimmons, Donald NEW YORK STATE DEPARTMENT OF HEALTH-.. �
Vital Records Section Burial - Transit Permit
Name First Donald Middle James Laskitzsimmons Sex Male
Date 0off/D a 014 Age 55 years If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
X Ciwn or Vile Greenfield Street Address 395 Wilton Road
Manner of Death❑Natural Cause Accident Homicide Suicide Undetermined Pending
ILI Circumstances Investigation
ut Medical Certifier Name Title
iti Joseph Dudek Attending Physician
Addrab Patroon Creek Blvd, Albany, New York
Death Certificate Filed District Number Register Number
Cwn or ViNgxx Greenfield 4557 5
❑Burial Date Cemetery or Crematory
06/11/2014 Pine View Crematorium['Entombment Address
Ni ['CremationQueensbury, New York
Date Place Removed
Z❑Removal and/or Held
2 and/orF.i Address
Cl) Hold
Date Point of
DiEl Transportation Shipment •
0 by Common Destination
Carrier
ilWQ Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Reg istL tio6n4 Number
Name of Funeral Home Compassionate Funeral Care, Inc. 3
Address 402 Maple Avenue, Saratoga Springs, N Y 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address .
cc
L
97 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/11/2014 Registrar of Vital Statistics
(signature)
District Number 4557 Place Greenfield
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition t+`(2.-14 Place of Disposition f�al aw('or.w-
(address)
Lu
tfl
CC (section) (lot number) (grave number)
0 Name of Sexton or Per on in Charge of Premises ���'� 4.1f
2► (please print)
Signature ��' Title CatTIA101,
(over)
DOH-1555 (02/2004)