O'Donnell, Francis NEW YORK STATE DEPARTMENT OF HEALTH it 1.01
Vital Records Section r • .. k Burial - Transit Permit
Name First Middle M LtiDonnell Sex Male
Francis
Date of Death Age If Veteran of U.S. Armed Forces,
01/30/2012 68 years War or Dates No
} Place of Death Hospital, Institution or
City, ToYLXYAVAISYJC Schenectady Street Address Ellis Hospital
ilk Manner of Death 3Natural Cause El Accident ❑Homicide ❑Suicide El❑Undetermined ❑Pending
Ili[ Circumstances Investigation
0.
la Medical Certifier Name Title
Micheline Ford M D
Address
124 Rosa Road, Schenectady, Ny 12308
Oiili Death Certificate Filed District Number Register Number
iilig City, Toip(X(X cviftxX Schenectady 4601 104
iiiii El Burial Date Cemetery or Crematory
02/01/2012 Pineview Crematory
0 Entombment Address
il Daremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
2 and/or
� Address
tO
Hold
Date Point of
Transportation Shipment
0 by Common Destination
Ri Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiii Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00440
Address
7 Sherman Ave., Corinth, N.Y.
qili Name of Funeral Firm Making Disposition or to Whom
F•0 Remains are Shipped, If Other than Above
2 Address
la
Permission is hereby ranted to dispose of the human remains descril7d apAve a d'cat
Date Issued 01/31/2012 Registrar of Vital Statistics 1 lf`'`�` S
(sigbature)
1111111111 District Number 4601 Place Schenectady
;::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
;
ill Date of Disposition D-D.- actz. Place of Disposition arie .J. <LJ Cremndor,`v w
2 (address)
Lu
CII
11 (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises &k.ielle
j. 1 (please print)
Signature s 9/1( Title Cr-ep..04 t y45s1 -
(over)
DOH-1555 (02/2004)