Donnelly, John # -3t
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
gi Name First Middle Last Sex
John A. Donnelly Male
Date of Death Age If Veteran of U.S. Armed Forces,
Dec.Mi 09, 201 '3 9'3_ yrs_ War or Dates WWII
i4 Place of Death Hospital, Institution or
Cit , own r Village Kingsbury Street Address 1 30 Rock City Rd.
Man o Death ❑x Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
Circumstances Investigation_
tua Medical Certifier Name Title
CI Robert W. Spnzo MD.
Address NN
Death C "ficate Filed82 Park St. , Glens Distnc F1umbe� 1 2801 Register Number
City own r Village Kingsbury 5'7c7 I ?
Date Cemetery or Crematory
❑Burial Dec. 06, 201a PineView Crematorium
Address
Cremation Town of Queensbury, NY.
Date Place Removed
0❑Removal and/or Held
�- and/or Address
gHold
O Date Point of
134❑Transportation Shipment
G by Common Destination
Carrier
I:Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Mason Funeral Home Registration
e-01 1 1 7 Number
{''. Name of Funeral Home
Address 18 George St. , Fort Ann, NY. 12827
'>''>' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
Permission is hereby granted to dispose of the human rem��a
((��
ins described above as indicated.
Date Issued 1 2/06/1 3 Registrar of Vital Statistics y`5 -�- (,• __Q-;t
(signature)
S76 Town of Kingsbury, NY.
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- ;� `'
I Date of Disposition 0.-�t`t3 Place of Disposition -k"��If� ' trr,..-drdt'—
' (address)
uIJ
to
CC (section) of number) (grave number)
GName of Sexton or Person in Charge of Premises (..'iL i:w4+-
g (please print)
w Signature Title Cri)ti=iM 'z-
(over)
DOH-1555 (9/98)