Persons, Douglas • .
NEW YORK STATE DEPARTMENT OF HEALTH —,-,` Burial = Transit Permit
Vital Records Section
Name First Middle LastD ` Sex
I.
�c�V (� S l< • / )1. S o,.,S JI G-e v'
Date of De ( Age If Veteran of U.S.Armed Forces, /
�/y//g" I <Po 1 War or Dates Ai I,
l, Place o:Death i Hos - on or
City T ovr r Village Q 0 ,Js a Street A - �-7 ST6.-f/M,'J ter Z.a"'cr
Manner of Death m Natural Cause 0 A cident []Homicide j Suicide Q Undetermined [,Pending
t Circumstances Investigation
IA Medical Certifier Name Title
0 1 s of u s 6.1.".. S O o rz i ,e- 0 8-1..E- n., •./ ':jj,
Address
Ito/ C. -1, 20 , Q u Aist3 Ai/ i2-a:'0y
Death ertificate Filed / District Ninber I Register Number
.City Tavu or Village C� 0(d A Js( L i - L 1 1 13
DeUriai 1 Date 1 Cemetery a�Cremat t '
En4atnbmer►Y4 �'l i II _ lli,04..i, V/to...,)
Address Cy ^ r Lj
Date I Place Removedrut
/
€riRemoval i and/or Held
a dior Address
E! Hold
81{{
I Date Point of
Osip Transportation f ( Shipment
3 i v Common Destination
1 Carrier
1 f DiQiinterment
Date i Cemetery Address
i I Date [Cemetery Address
,,.I Fianterment , I
-,": PerTnit issued toI Registration Number
Baker Funeral Home 01130
' Na-„a cf Funeral Home
1 Ad` ess -
11 Lafayette St., Queensbury, NY 12804
i Name of Funeral Firm Making Disposition or to Whom
1 RLc lain s are Shipped, If Other than Above
i Address - --
i
"I PCi' aiCal is hereby,granted to dispose at the human remains described above as indicated,
r;::
• Dee issued g- 1"1 - �0 12 Registrar of Vital Statistics '- 'Iti�e .L e --
(signature)
. District Number S 1,S'"( Place O v e e-n S h ✓N
4 ;:e �:J that the remains of the decedent identified above were disposed of in accordance with this permit on:
t--f
Mi
j Da.i.e ,' Disposition e a..4-1 Place of Disposition pills, Mi f ILd C,re,nril'T y .
c.I (address)
f
61)
(section (rot number) (grave number)
Oi i Name of Sexton or Person in Charge of Premises -fir-LY S'tUe r S
1 (please print)
1 Signature ., -�` Title .,C�,
(over)
DOH-1555 (02/2004)