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Cole, Douglas #go NEW YORK STATE DEPARTMENT OF HEALTI-u t Vital Records Section Burial - Transit Permit Name First Middle Last Sex Douglas A. Cole Male Date of Death Age If Veteran of U.S. Armed Forces, `' December 29,2017 63 War or Dates :F' Place of Death Hospital, Institution or •Z City, Town or Village Johnsburg Street Address 105 Oven Mountain Rd. pManner of Death g Natural Cause Accident Homicide Suicide Undetermined Pending to Circumstances Investigation w= Medical Certifier Name Title o Michael R.Bell Address BR UN,Warrensburg,NY 12885 Death Certificate Filed District Number Register Number City, Town or Village Johnsburg 5655 © 1 ❑Burial Date Cemetery or Crematory Ill Entombment January 2,2018 Pine View Crematory Address ®Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed ZO n Removal and/or Held and/or Address F Hold 0 O Date Point of NTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00037 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above AAddress ttt ' Permission is h re y granted to dispose of the human remai s escribed abov as in ' ated. Date Issued O Registrar of Vital Statistics 4C.?(4 r f c', ., (signature) District Number 5655 Place Johnsburg I certify that the remains of the decedent identified above were disposed pof'in accordance with this permit on: Z Dispositionq)J Disposition '1 V ( i /'r.- W Date of ►� g Place of ,,,,,, J ,�, v W (address) co re (section) (lot nu ber) (grave number) Q Name of Sexton or Person in Charge of Premises 1i n, --ral' Z �/ (please print) 4 Signature �"1 Title ilif fillp (over) DOH-1555 (02/2004)