Dougher, Joseph NEW YORK STATE DEPARTMENT OF HEALTH # S Zqq
Vital Records Section
Burial - Transit Permit
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Name First Middle Last Sex
Tegi
Joseph M. Dougher Male
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ia Date of Death Age If Veteran of U.S. Armed Forces,
hei October 24, 2011 88 War or Dates World War II
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Philip J. Gara, Dr.
Address
fR
318 Broadway Fort Edward 12828
Death Certificate Filed District Numbe Register Number
City, Town or Village ) ,5 i
0 Burial Date Cemetery or Crematory
October 26, 2011 Pine View
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
ti ❑ Disinterment Date Cemetery Address
El Reinterment
Date Cemetery Address
T: Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r Permission is he eby anted to dispose of the human m ins describ bove s indicated.
Date Issued/6
Registrar of Vital Statisti
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District Number 7""------ Place I1 7G id l
4 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.£' Date of Disposition 10/26/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Wit`
(section) (lot number (grave number)
{ Name of Sexton or Person in Charge oy Premises as4ori.ti 84,4
j)� (please print)
SignatureiL Title CQr r► i i og.
(over)
DOH-1555 (02/2004)