Mumblo, Donald NEW YORK STATE DEPARTMENT OF HEALTH, , , # 3%
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald Francis Mumblo Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 14, 2012 81 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
W' Manner of Death 0 Natural Cause n Accident Homicide Suicide 1-1 Undetermined El❑ Pending
Circumstances Investigation
W' Medical Certifier Name Title
Philip J Gara Jr. MD,
Address
327 Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
j City, Town or Village 5601 .-"? S 3
❑Burial Date Cemetery or Crematory
July 20, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
o and/or Address
Hold
( Date Point of
,,, 0 Transportation Shipment
0) by Common Destination
# Carrier
Disinterment Date Cemetery Address
Reinterment11
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
L Remains are Shipped, If Other than Above
2: Address
IX
W'.
" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued —if i 6 /,-2 Registrar of Vital Statistics (..1,30 Q. l./`) A,-- a
(signature)
District Number 5601 Place �j LQi.S 7YA Y \ S I Nis y IQ`ib'
4
-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition 1-t3-12 Place of Disposition 1
� P p �+.,uUcw w-for 1.t�
(address)
W
69
.}
rt (section) (Jot number) (grave number)
O• Name of Sexton or Person in Char a of Premises Ar r stiff-et" S„
.z' (p1ase print)
W' Signature Title Cite.tomo it,
(over)
DOH-1555 (02/2004)