Burt Sr., Donald Richard . . )ICI
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald Richard Burt Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/13/2021 75 Years War or Dates
(.. Place of Death Hospital,Institution or
W City,Town or Village Warrensburg Town Street Address 21 Smith Street,Warrensburg Town, New York 12885
O Manner of Death Natural Cause Accident ❑Homicide Suicide El Undetermined El Pending
UJ
✓ Circumstances Investigation
WG Medical Certifier Name Title
Eileen Spinelli NP
Address
Carey Rd,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Warrensburg 5660 5
Burial Date Cemetery,Crematory or Facility Name
02/17/2021 Pine View Crematory
0 Entombment Address
X❑Cremation Queensbury,New York
0 Donation
O Removal Date Place Removed
El
and/or and/or Held
F- Hold Address
N ❑Transportation Date Point of
G by Common Shipment
Carrier Destination
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 Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
f` Remains are Shipped,If Other than Above
ORM
2 Address
Q
W
dPermission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/16/2021 Registrar of Vital Statistics 2'amela.4fLthyd&E/ctronica/TSigned)
(signature)
District Number 5660 Place Warrensburg, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 2-I g iv Place of Disposition L
111
address/
W
N
_ (section/ (!o umber) (grave number)
gName of Sexton or Person in Charge of P emises �` "'
p ease print
LIJ Signature Title f!7tevoi+477a
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014 54 6
Receipt
Human remains of delivered on , 20"
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ,