Bush, Donald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section j Burial - Transit Permit
Name First Middle - Last Sex
Donald A. Bush Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/21/2013 91 years War or Dates WWII
I Place of Death Hospital, Institution or
City, Tow */iX Glens Falls Street Address Glens Falls Hospital
0 Manner of Death 0 latural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
Lit Circumstances Investigation
tu Medical Certifier Name Title
O Thoma&F Hafer M D
Address
9 Carey Road Queensbury, N Y
Death Certificate Filed District Number Register Number
City, TowRX3CiXX- Glens Falls 5601 306
❑Burial Date Cemetery or Crematory
❑Entombment 07/22/2013 Pine View Crematorium
Address
FCremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
91—land/or
Address
6/
Hold
O Date Point of
• ❑Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01078
Address
136 Main Street South Glens Falls, N Y 12803
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
2 Address
it
ui
mi Permission is hereby granted to dispose of the human remains described above as,indicated.
Date Issued 07/22/2013 Registrar of Vital Statistics l,/OCAA-I)'`^Q LA)�,---^-c'UM
(signature)
District Number 5601 Place Glens FaIIS4 (J U(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I l
ILI Date of Disposition 1-lt{-t3 Place of Disposition eivAlitt", L.termidt40.►
(address)
14.1
tO
CC (section) (Jot n ber) S (grave number)
ci Name of Sexton or Perso in Charge of Premises di. tto r e►+vit`t
(p/e se print)
ILISignature '1-". Title anon P
(over)
DOH-1555 (02/2004)