O'Brien, Donald NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Donald T. O'Brien Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 9, 2012 88 _ War or Dates World War II
:;• , Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
ci Manner of Death X Natural Cause I !Accident I I Homicide Suicide Undetermined Pending
to Circumstances Investigation
; a Medical Certifier Name Title
IP
Address
Death Certificate Filed I District Number Register N ber
City, Town or Village Glens Falls 5601 _.5 C i
❑Burial Date Cemetery or Crematory
III Entombment December 11, 2012 Pine View Crematorium
Address
0 Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
O Date Point of
O.
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
• 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
k* Remains are Shipped, If Other than Above
S, Address
U.1
a;:. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12 i i i t f 2 Registrar of Vital Statistics lam)0..4-tn.Q,
(signature)
District Number 5601 Place Glens Falls, /"/ V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition IL-i2-i1 Place of Disposition 4? 1Q1 C vri„�'
2 (address)
W
U)
re (section) AO
(lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises lh���-
Z ! (please print)
W 4--Signature L Title A--idet
, (over)
DOH-1555(02/2004)