Madden, Donald /YORK STATE DEPARTMENT OF HEALTH Z2%
Records Section
, N.,
Burial - Transit Permit
Name First Middle Last Sex
Donald Joseph Madden Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 1, 2012 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death X❑ Natural Cause Eil Accident ❑ Homicide ❑ Suicide ❑ Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Philip J. Gara, Dr.
I.. Address
318 Broadway Fort Edward 12828
'! Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward �`I f c„l 2
❑Burial Date Cemetery or Crematory
May 2, 2012 Pine View
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
„ ❑ Removal and/or Held
. and/or Address
Hold
stt Date Point of
,£El TransportationShipment
by Common Destination
Carrier
Date CemeteryAddress
• ❑ Disinterment
1 Date Cemetery Address
" ❑ Reinterment
ii
Permit Issued to Registration Number
1 Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
': Remains are Shipped, If Other than Above
Address
+ Permission is hereby granted to dispose of the human remain describe b ve as indicated.
Date Issued,� �,i 2 Registrar of Vital Statistics '
(signature)
District Number 57i 3 Place ��,4 nii 1J /Zc
SPy I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/02/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) c (grave number)
Name of Sexton or Person in Charge Premises do-Alifikt( J P.,qk1
(please print)
Signature �� Title C0414)1 da
(over)
DOH-1555 (02/2004)