Friday, Donald J ( '1c
- /
(A
NEW YORK STATE DEPARTMENT OF HEALTH
j1'
Bureau of Vital.Records Burial - Transit Permu
Name First Middle �1 Last Sex
Donald J.Friday Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/04/2022 95 Years War or Dates 1945-1946
H Place of Death Hospital,Institution or
WCity,Town or Village Bolton Town Street Address 28 Brook Street,Bolton Town,New York 12814
p Manner of Death ❑X Natural Cause Accident ❑Homicide Suicide ❑Undetermined Pending
V Circumstances Investigation
W Medical Certifier Name Title
C Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Bolton District Number Register Number
City,Town or Village 5650 8
Burial Date Cemetery,Crematory or Facility Name
10/06/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
U)EITransportation Shipment
Q by Common
Carrier Destination
El
Disinterment
Date Cemetery Address
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/05/2022 Registrar of Vital Statistics Jodi'Petteys(E(ectronwa1Ty Signed)
(signature)
District Number 5650 Place Town Of Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition J01 61 L2 Place of Disposition eiZuv � ��`
2 (address)
W
CC (section) _ (lot nu ) (grave number)
8 4 n r y.w[11
Name of Sexton or Person in Charge of Premises
�� (please print)
W Signature z
g
-1—‹*-- Title CZ 1A-7
DOH-1555(o7/t8)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20 '\
Pine View Cemetery Representing the funeral home nanlefl op burial permit
Official Funeral Directors Reg.or License#