Douglas, Barbara NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
FA Name First Middle Last Sex
le Barbara R.Douglas Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/23/2018 94 Years War or Dates
Place of Death Hospital, Institution` r�("bi'"
City, Town or Village Johnsburg Town Street Address Elderwood at North Creek
• Manner of Death Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
.= James Hindson MD
111 Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City, Town or Village North Creek 5655 29
LI❑Burial Date Cemetery or Crematory
M. 10/24/2018 Pine View Crematory
❑Entombment Address
et ®Cremation Queensbury Town, New York
Date Place Removed
❑• Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Eg
❑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.
0 Date Issued 10/23/2018 Registrar of Vital Statistics 1cth(eenC.Lorahg(ectronica1(ySigned)
0 (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:
ha Date of Disposition /0j Z4 lig Place of Disposition f j_. ( t J
(address)
(section) (lot mber) (grave number)
✓ g C it
Name of Sexton or Person in Charge o Premises 6^r'' r J x�^'�
•- (please print)
Signature (r( yllc Title 117f114fqt
(over)
DOH-1555 (02/2004)