Wilson, Douglas NEW YORK STATE DEPARTMENT OF HEALTH i 0 ) t b
t
Vital Records Section Burial - Transit Perm
Name First Middle Last Sex
Douglas Wilson Male
Date of Death Age If Veteran of U.S. Armed Forces,
t 09/17/2017 74 War or Dates
Place of Death r Hospital, Institution or663D r A'N'> B/QitTjuh,
F City, Town or Village Brert�ieke/17 C.a2/ Street Address Deceased's Residence �
Manner of Death
1Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier sc /,7 �o (tJe /l R
t Address
_tv -,)-a ---3 RAe y c1 h . 77 s 7
m Death Certificate Filed District Number Registe Number
.oi3O City, Town or Village y t (c"— ��1,p�❑Burial Date Cemetery or ,rpmato n �— '
3w❑ fie (/Entombment 09/18/2017 /, l r/j! �`��L��!
Address
®Cremation
ttit
Date Place Removed
Removal and/or Held
r:
.. and/or Address
Hold
Date Point of
t ❑Transportation Shipment
by Common Destination
Carrier
a9 Date Cemetery Address
❑ Disinterment
0 Reinterment
Date Cemetery Address
At
iAt Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
f ` Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
r Y 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 rem 'n escribed abo as' dicate
VS
:41,;: Registrar of Vital Statistics
Date Issued - - g - g-
..
(signature)
eV it District Number Sa t- Place 74 —j(,)✓)
e i a•• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
Date of Disposition q�toff)f) Place of Disposition �q,.U4.� ( c-�u(v..
(address)
(section) (ii,
(lotnumber) /` (grave number)
Name of Sexton or Person in Charge of Premises S4.4./4// (plee print)
Signature Title ((t2Mti-
(over)
DOH-1555(02/2004)
i