Doner Sr, William Ti�
NEW YORK STATE DEPARTMENT OF HEALTH t .s
Vital Records Section Burial - Transit Permit
e- Name First Middle Last Sex
William Mahlon Doner,Sr. Male
:: Date of Death Age If Veteran of U.S. Armed Forces,
July 22, 2014 74 War or Dates US Navy
:: Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
Manner of Death [x Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
iMedical Certifier Name Title
Melissa Decker,MD
'f: Address
:: 9 Carey Road,Queensbury,NY
Death Certificate Filed District Number Register Number
:.:• City, Town or Village Glens Falls,NY 5601
e. ❑Burial Date Cemetery or Crematory
July 24, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
}' Hold
O Date Point of
yn Transportation Shipment
p' by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
::: : Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
::j: Address
53 Quaker Road, Queensbury,NY 12804
, r' 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 remains described above as indicated.
:�1 Date Issued 1 1-2 3 1 f f Registrar of Vital Statistics _ UOCAM,,,-.,a, t/J
Ye (sign.
District Number 5601 Place Glens Falls,NY
I certify that the remains of thej decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition �ag'.-/y Place of Disposition g/vi(Ai � ��
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W (address)
N
CL
(section) � (lot umber)/ (grave number)
p• Name of Sexton or in C r of Premises SLti .' � '�2w/r1,7 c/
Z (please print) ,(
W �� J
Signature Title � 2 /4J a
(over)
DOH-1555(02/2004)