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Boutelle, Donald H
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donald H Boutelle Male Date of Death Age If Veteran of US.Armed Forces, 09/04/2021 97 Years War or Dates 1942-45 Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation pManner of Death ©Natural Cause Accident Homicide Suicide El UndeterminedPending U Circumstances Investigation W Medical Certifier Name Title Courtney Diamond NP Address 170 Warren St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 383 ElBurial Date Cemetery,Crematory or Facility Name 09/07/2021 Plneview Crematory ElEntombment Address ElCremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or , and/or Held F- Hold Address 0 IB. Date Point of Cl) ❑Transportation Q by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Date Cemetery Address Reinterment 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 1— Remains are Shipped,If Other than Above 2 Address CC W C" Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/07/2021 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z / -t— W Date of Disposition �I�� Z� Place of Disposition �,�, r (address) W N (section) 1(lot number) (grave number) I Name of Sexton or Person in Charge of Premises A c L Si Z (ple print) W Signature � Title AO it Rig DOH-1555(07/18)p 1 of 2 T A 1 51 e Public Health Law Sec. 4145(2b) Receipt • Human remains of - delivered on , 20 ' Pine View Cemetery Resenting the funeral home nameg on burial permit Official Funeral Directors Reg.or License# I '' ': '