McDonald, Francis J 4 ,( 3
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Francis J McDonald Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/06/2022 93 Years War or Dates Army
H
Place of Death Hospital,Institution or
Z City,Town or Village Bolton Town Street Address 4875 Lake Shore Drive, Bolton Town, New York 12814
W Manner of Death ❑ ❑Undetermined Pending
0 Natural Cause Accident Homicide Suicide
W Circumstances Investigation
W Medical Certifier Name Title
CI Bryan Smead MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Bolton District Number Register Number
City,Town or Village 5650 10
HBurial Date Cemetery,Crematory or Facility Name
12/08/2022 Pine View Crematory
Entombment Address
IlCremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held •
— Hold Address
U)
0
Date Point of
(I) Transportation Shipment
Bj by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F.. Remains are Shipped,If Other than Above
2 Address
Q
ILLI
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/07/2022 Registrar of Vital Statistics Jodi cPetteys(ECectronicalTy 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:
ZZDate of Disposition I z I I i l2 Place of Disposition �( .•t� L---
UJ
(address)
IW
NCC (section/ number) (grave number)
g Name of Sexton or Person in Charge of Premises /111 (lot
"t S,,, h tt
z
(ple�e print)
IU a Title /26inl1 I6�Signature
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Cemetery Representing the funeral home named on burial permit
Funeral Directors Reg.or License#