Bolduc, Donald M. # I 11
NEW YORK STATE DEPARTMENT OF HEALTH Burial- Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald M Bolduc Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/15/2021 61 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
p Manner of Death XI NaturalCause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Yoram Amsalem MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 145
❑Burial Date Cemetery,Crematory or Facility Name
02/17/2021 Pineview Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
▪Donation
❑Removal Date Place Removed
and/or and/or Held
~
N Hold Address
O
a 1-1 Date Point of
CO ❑Transportation
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/17/2021 Registrar of Vital Statistics John Paul Franck(Electronically Signed)
/signature/
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l— Fj1,
WDate of Disposition 21 diZ1 Place of Disposition ��---
(address
W
CC (section) (to umer) (grave number)
0 Name of Sexton or Person in Charge of Pre ises Pvt.
Z please prim
W Title ` y'"u a.'
Signature
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 14 5 1
Receipt
Human remains of delivered on , 20 i.
'ine View Cemetery Representing the funeral home named on burial permit
Funeral Directors Reg.or License#