Loading...
Atkinson Sr., Donald Ray it 35t, NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donald Ray Atkinson Sr Male Date of Death Age If Veteran of U.S.Armed Forces, 05/04/2021 64 Years War or Dates l` Place of Death Hospital,Institution or Z City,Town or Village Lake George Town Street Address 7C Thomson Avenue,Lake George Town,New York 12845 ILI 0 Manner of Death I:IUndetermined Pending W ©Natural Cause Accident Homicide Suicide Circumstances Investigation W Medical Certifier Name Title CI Michael Adams MD Address 1448 Route 9,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Lake George 5651 8 ❑Burial Date Cemetery,Crematory or Facility Name 05/06/2021 Pine View Crematorium ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Z • ❑Removal Date Place Removed and/or and/or Held F- Hold Address N 0 d Date Point of Cl) ❑Transportation p by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1- Remains are Shipped,If Other than Above 5 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/06/2021 Registrar of Vital Statistics Patricia c,9Kc7(y'nney-Sckuster(ECectronicac1ySigned) (signature) District Number 5651 Place Lake George, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition S1� I it Place of Disposition "I ' ,� 4 (address/ W Nit' (section) a (lot number) (grave number) 8 Name of Sexton or Person in Charge of Pr mises An. .5 ^.4 t Z (pleaMil--print) LU �/' Title `k}70it Signature DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 01 f 7 64 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#