Russell, Douglas NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Douglas Arthur Russell Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/26/2017 55 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ['Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Campanie NP
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 608
, ®Burial Date Cemetery or Crematory
Zu 11/30/2017 Pine View Cemetery
❑ERA°tbrr'ent Address
❑Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
R, and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
7 Carrier
r Date Cemetery Address
❑Disinterment
2 ❑Reinterment Date Cemetery Address
eh
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
Address
_:< Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/27/2017 Registrar of Vital Statistics q(g6ertACurtis Efectronicailysigned.
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above wer isposed o in acc rdance with this permit on:
Date of Disposition 111.30 I h- Place of Disposi ' n Z. I
i I it— F I
ILL • a-061
address)
cti n) (lot number) (grave number)
2 Name of S ton or Person in Charge of Premi s ��/� �� �
�/• .� (p se print)
1 Signatur "� Title •
(over)
DOH-1555 (02/2004)
RUSSELL (SA)
Owner
Douglas Russell
Address Plot
63 White Birch Estates Fort Edward NY 12828 Seneca
Phone # Lot #
518-222-0404 14 F
Deed # Date
4028 11 /30/2017
Cost Foundation Y - N
700
Location
Bounded to the North by Hermance, East by Vacant
South by Vacant, and West by Rawson
Remarks
Record of Interments
1 Douglas Russell 11 /30/2017 (FB) 6
2 7
3 8
4 9
5 10
e. V IV
A
S vY t * E
0 ,r
S
RUSSELL
NAME Douglas A. Russe IIS Age: 55
Lot Owner:
Douglas Russell
Lot# Grave#
Seneca #14F 1
Case:
Concrete
Died: Interred:
11 /26/2017 11 /30/2017
Funeral Home:
Bakers Funeral Home
Cemetery: Pine View Cemetery