Dougherty, Stephen Thomas i • t 3 23
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Stephen Thomas Dougherty Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/08/2020 90 Years War or Dates 1952-1954
i.— Place of Death Hospital,Institution or
W City,Town or Village Glens Falls —7Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
C3 Mannerof Death Natural Cause Accident Homicide Suicide Ej Undetermined Pending
Uj V Circumstances Investigation
W Medical Certifier Name Title
Jean Flanagan MD
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 166
Burial Date Cemetery,Crematory or Facility Name
04/09/2020 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
O and/or and/or Held
H N Hold Address
O
0- Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
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
�.. Remains are Shipped,If Other than Above
Address
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/09/2020 Registrar of Vital Statistics 96,6ea,4ndrew Curti (E&tronkaglySrgned)
(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:
i—
WDate of Disposition I/D � Place of Disposition � •—�`
W (address)
W
tl? (section) (lot nu m (grave number)
aName of Sexton or Person in Charge o Premises �p se print)
Z (
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named.on burial permit
Official Funeral Directors Reg.or License#