Douros, George NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George W Douros Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/20/2017 80 Years War or Dates
Ik:. Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitati
tp Manner of Death 0 Natural Cause 12 Accident ci Homicide Suicide ri Undetermined 17 Pending
Circumstances Investigation
W Medical Certifier Name Title
Gwendolyn Morris-Dickinson PA
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 447
®Burial Date Cemetery or Crematory
08/25/2017 Pine View cemetery
['Entombment Address
❑Cremation Queensbury Town, New York
Date Place Removed
C ❑Removal and/or Held
and/or Address
Hold
O Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
El
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
h-- Remains are Shipped, If Other than Above
• Address
W
11,. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/22/2017 Registrar of Vital StatisticsRe6ertilCurtiss 'electronicaffySigned
(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:
Ui Date of Disposition Place of Disposition
LU (address)
N
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises
Zr (please print)
W Signature Title
(over)
DOH-1555(02/2004)