Wilde, Douglas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Douglas E.Wilde Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/29/2018 67 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Johnsburg Town Street Address Adirondack Tri-County Nursing And Rehabilitation Center,Inc.
,.- Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
James Hindson MD
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City, Town or Village North Creek 5655 10
❑Burial Date Cemetery or Crematory
04/02/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
El❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
I:Disinterment
Date Cemetery Address
❑Renterment Date Cemetery Address
tp- Permit Issued to Registration Number
111 Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/02/2018 Registrar of Vital Statistics then C.Lorah(E(ectronica1Ty Signed)
(signature)
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition '-j/3113 Place of Disposition
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 14r '""'41
( lease print)
Signature Title
alft �
(over)
DOH-1555 (02/2004)