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Swart, Douglas R.
L v a # 0 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Douglas R Swart Male Date of Death Age If Veteran of U.S.Armed Forces, 01/14/2020 63 Years War or Dates II.— Place of Death Hospital,Institution or Z City,Town or Village Hadley Hamlet Street Address 4114 Rockwell Street, Hadley Hamlet, New York 12835 LLI p Manner of Death © Natural Cause Accident Homicide Suicide Undetermined Pending LLI Circumstances Investigation W Medical Certifier Name Title 0 Charles Yun MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Hadley 4558 2 Burial Date Cemetery,Crematory or Facility Name 01/15/2020 Pine View Crematory Entombment Address iCremation Queensbury Town, New York Donation and/or Removal Date Place Removed and/or Held H Hold Address 0 IL Date Point of CO) Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition orto Whom Remains are Shipped,If Other than Above 2 Address cc W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/15/2020 Registrar of Vital Statistics Pauline G Smead(Electronically Signed) (signature) District Number 4558 Place Hadley, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition ' Z6 Place of Disposition LU (address) W N (section) /of num / (grave number) Q 0 kWh o Name of Sexton or Person in Char of Premises Z lease print) W Signature Title fWn DO H-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013243 Receipt 1�OUT Human remains of delivered on , 20 1� -mot •'j'..1 ' � ' Pine View cemetery Rep�esentinjthe funeral home named on burial permit Official Funeral Directors Reg.or License#