Islier, Donald P NEW YORK STATE DEPARTMENTOFHEAI.TH Burial - Transit Permit
Bureau of Bbstatistics-Vaal Records Section
Frst
Sex
Name » Lai
Date of Death Age If Veteran of U.S.Armed Forces,
War or Dates
Place of Death
Hospital, Institution or
: ` City,Town or Village ; Street Address
Imo:. Cause of Death "»
Medical Certifier Name�I�:tuna.�.:.:....:.,..»:...,...»».w.,r..:.:»�.y.....�,:.�.,..,.:..::.,.:.»..:�.:�.:,,..:::::::.:.,.,»,..:...:�»�.�,....w:.�..,
j; Title
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Address
90 South Street Glens Falls, New York 12801
Death::. ..............................................».:........,.»». ..,.:.»..»...:....:::...................,....... .. ...........................
Certificate Filed District Number Register Number
City,Town or Village Glens Falls
Date Cemetery or Crematory
Q Burial,al Nov. 4, 1991 Pine View Cremator .:........
y
..
Cremation Address »...................... ...........................:......... .........
Queensbury, New York
.::.Date... .» , _ ....... Place Removedw.» _:.. :.:...:.....:..»» w k�,:., :.......N.:.�.... :..:...:.............._..
O, ❑ Removal and/or Held
-< and/or Hold"",-----, ,w .�::..:� »,» M�.:.»...,..M: ».......»,..».»,.,..,......».....», .,,,. ,,............:...:..................................
n' Date Point of
6 Transportation by}
Common Carrier Shipment
` ]' s De'stinatori..,..:..,...,.,.,�....,».:.�,.,.,,w..,,....,.»,.»�.,»�.,.,.,.�,.,_..,.�.»...w.,�.,M,.:,..,::,»:.:..»..:.....,»...w:.»,.......,.:..,................�....:.......:...
z -
Disinterment
Date....,.... »... .»: ..� » Cemetery Addrass.x. w..:..... �..,...� : :�::...,.....,.. ...»,,............,...............:.:.µ.»: .
Reinterment Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Reqan & Dennv Funeral Home
01602
Address
26 Quaker Road Queensb , New York » 12804 »
w; Name'of Funeral Firm Making'Disposition or to Whom
>" Remains are Shipped, If Other than Above
W.. Address
???� Permission Is hereby granted to dispose of the human a aIns describ a a �cad.Date Issued Registrar of Vital Statistics ed `
re
)
District Number Place
' > I certify that the remains of the decedent identified above were disposed of in aocordanc ith this permit on:
Zff Date of Disposition I` —/ Place of Disposition //�� �'/ � t��7/V/: 76W( )L10
(address)
(section) (lot number) (grave number)
fl' Name of Sexton r Person i Char a of Pre ' as �,�, -,� ,
Owe prin
Au
Signature )Title d,
DOH-1555(9/86)p 1 of 2(formerly VS-61)