Mattison, Donald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald William Mattison Male
, Date of Death Age If Veteran of U.S. Armed Forces,
October 15, 2012 59 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Deathm
vlj Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined 1--I Pending
CircumstancesInvestigation
Medical Certifier Name Title
Sean Bain, M.D. Dr.
;A; Address
100 Park Street Glens Falls, NY 12801
41 Death Certificate Filed District Numberr i ^ram l Register_NumI er
City, Town or Village ")UX, r }S
0 Burial Date Cemetery or Crematory
October 16, 2012 Pine View Crematory
❑Entombment Address
.<®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
'7 I I and/or
Address
,-- Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
it
❑ Reinterment Date Cemetery Address
34
, Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
4 Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains d:z2y177 as i ed.
Date Issued O /4 2O/2— Registrar of Vital Statistics
< ,. //"�� (signature)
District Number 5 L2/ Place �p4,,d ff/A / 7
4 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/16/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) _ (lot number) (grave number)
- Name of Sexton or Person in Ch rge of Premises Z' r,s'I t.� s0„44-
(please print)
Signature /tt---
Title C �' ,e
(over)
DOH-1555 (02/2004)