Edmunds, Douglas NEW YORK STATE DEPARTMENT OF HEALTH - Burial . Transit Permit
Vital Records Section
Name First Middle Last Sex
Douglas E.Edmunds Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/07/2018 84 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
Manner of Death j Natural Cause El Accident 0 Homicide Ei Suicide El Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 34
OBurial Date Cemetery or Crematory
03/09/2018 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
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
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 03/09/2018 Registrar of Vital Statistics Caroline?(Barber(ECectronica(CySigned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3/ ill Place of Disposition „v 4-et,
(address)
(section) ri(lot number) (grave number)
Name of Sexton or Person in Charge of Premises `+�,,
(phase prin�j
Signature Title AlKIK
(over)
DOH-1555 (02/2004)