Donnelly, George 71
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section - Burial - Transit Permit
Name First Middle Last Sex
George • Alien Donnelly Male
Date of Death Age If Veteran of U.S. Armed Forces,
11 /30/2014 85 yrs. _ War or Dates No
14 Place of Death Hospital, Institution or
Town of
LuZ City, Town or Village Ticonderoga Street Address 269 vineyard Road
O Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined ❑Pending
IL Circumstances Investigation
tu Medical Certifier Name Title
0 Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 65
<' DBurial Date Cemetery or Crematory
❑Entombment 1 /(l /2 01 4 P n e V,, ewCrema F o_r,{y___._.
Address
Cremation Queensbury, NPw York
Date Place Removed
Z ❑Removal and/or Held
and/or Address
E Hold
CO
O Date Point of
041 ❑
Transportation Shipment
O by Common Destination
iiiii Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
ffli Name of Funeral Home Wilcox & Regan funeral home 01 821
gi Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
Cr
ILI
▪ Permission is hereby granted to dispose of the human remains a ribed abov indi e .
Mii Date Issued 1 2/ /2 1 3 Registrar of Vital Statistics ht.. � gn / . e
0 4
1 (signature)
District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k � �p •Lu Date of Disposition I i 1 0 PI Place of Disposition 1`ne-Le Ct-t',et()r
2 (address)
la
U
CC (section) lot number (grave number)
a Name of Sexton or Person in Charge of Premises (R,��' t�,
z
(p/ee print)
gi eliii Signature E/l. ..4,_— Title OLE PIiDe,
(over)
DOH-1555 (02/2004)