Ingleston, Doanld NEW YORK STATE DEPARTMENT OF HEALTH r l !
Vital Records Section Burial - Transit Permit
-° Name First Middle Last Sex
p. Donald Jack Ingleston Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 18, 2013 71 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address 1079 Burgoyne Ave Trailor 1
Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Darci Ann Gaiotti-Grubbs, M.D Dr.
Address
102 Park Street Glens Falls, NY 12801
Y Death Certificate Filed District Number Register Number
City, Town or Village � __ -2
❑Burial Date Cemetery or Crematory
November 20, 2013 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
' Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date CemeteryAddress
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is he by anted to dispose of the human r 'ns describe ove s indicated.
Date Issued//�-p ' Registrar of Vital Statistics/� +'if2l,
(sign re)
j District Numbe�71 Place G v -fil
I certify that the remains of the decedent identifie above were disposed of in accordance with this permit on:
Date of Disposition 11/20/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /� (lot number) (grave number)
Name of Sexton or Person in harge of remises h r,At r 3e nal
/^ ease print)
Signature G �,_ Title CPftZ .
(over)
DOH-1555 (02/2004)