Donnelly, Thomas NEW YORK STATE DEPARTMENT OF HEALTH .�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas E. Donnelly Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 4, 2013 70 War or Dates Yes
Place of Death Hospital, Institution or
Z City, Town or Village Lake George Street Address 33 Sullivan Rd (Queensbury)
pManner of Death n Natural Cause n Accident ( (Homicide n Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
0 John P. Stoutenburg Dr.
Address
Glens Falls Hosp,Glens Falls,NY 12801
Death Certificate Filed District Number Regiys er Number
City, Town or Village Queensbury 5657 b I
❑Burial Date Cemetery or Crematory
February 6, 2013 Pine View Creamtory
❑Entombment Address
0 Cremation Quaker Road, Queeensbury, NY 12804
Date Place Removed
Z [ (Removal and/or Held
and/or Address
• Hold
N
O Date Point of
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human r-m.ins described above indicated.
Date Issued! S Registrar of Vital Statistics
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
U
W Date of Disposition Z,lo-� Place of Disposition Z � a
2 (address)
W
U)
(section) (lot number (grave number)
Q Name of Sexton or Person in Charge of Premises �►r,. 3hait
Z (please print)
W r
Signature 1a Title 67 imiq-7dl
(over)
DOH-1555(02/2004)