Donaldson Jr, Clarence NEW YORK STATE DEPARTMENT OF HEAL?t 1 ' wS
Vital Records Section Burial - Transit Permit
Name First Middle • Last Sex
Clarence J , Donaldson ///'E Male
Date of Death Age If Veteran of U.S.Armed Forces,
I, August 6, 2013 7 b y War or Dates 1966-1967
2 Place of Death Hospital, Institution or
W City,Town,or Village Granville Street Address Haynes House of Hope
0 Manner of Death 0 Natural Cause ❑ Accident ❑Homicide Suicide E Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Joseph Mihindu, M.D. Dr.
0 Address
20 Murray Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Granville 95(p 3(1,
❑Burial Date Cemetery or Crematory
August 9, 3013 Pineview Crematorium
❑Entombment Address
E]Cremation Town of Queensbury Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
l' Hold
0 Date Point of
p ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
0 ❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
et
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued F' I r a b i3 Registrar of Vital Statistics
` si re)
District Number ,�c--15L4, Place Granville,New Yor
F
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 08/09/3013 Place of Disposition Pineview Crematorium
2 (address)
W
U)
0 (section) (I number) C f� (grave number)
0• Name of Sexton or Person in Charge of Premises At,ft f LItat ii
Z please print)
W
Signature411--- Title ,,
(over)
DOH-1555 (02/2004)