Donnelly, Rick NEW YORK STATE DEPARTMENT OF HEA,_TH ,, P
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rick R. Donnelly Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 19, 2013 66 War or Dates Vietnam
li Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
Cli Manner of Death 0 Natural Cause ❑ Accident 0 Homicide I I Suicide 11 Undetermined ri Pending
Circumstances Investigation
ILI Medical Certifier Name Title
CI John Sawyer, MD,
Address
453 Dixon Rd Queensbury, NY 12804
Death Certificate Filed District Number. Register umber
City, Town or Village Ctt�Ns 14(LS i/
0 Burial Date Cemetery or Crematory
January 23, 2013 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zriRemoval and/or Held
and/or Address
f- Hold
0 Date Point of
Transportation Shipment
V) by Common Destination
In Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
W
t Permission is hereby granted to dispose of the human remains described above as indiFated.
Date Issued /123 /2013 Registrar of Vital Statistics .,^.,)CM.1-...Q. LJ.,-A-c
(signature)
District Number S bC)/ Place 6 S 11 5,, '
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition I-i ' Place of Disposition �,,.eUtto Ci*�wrigoo—
W p �'t- p
2 (address)
w
(section) (lo number) (grave number)
z• Name of Sexton or Person in Char a of Premises Af+ ia— 5;44t
(please print)
III Signature Title Cei gig,
(over)
DOH-1555 (02/2004)