Cunningham, Douglas t A It 53 v
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First { _ Middle Last ' Sex
Douglas D. Cunningham I Male
Date of Death 1 Age j If Veteran of U.S. Armed Forces,
July 9, 2011 52 War or Dates _
H Place of Death Hospital, Institution or
IZ City, Town or Village Lake George j Street Address 3 Elizabeth Street
p Manner of Death n Natural Cause L.,Accident ! I Homicide X Suicide Undetermined Pending
W Circumstances Investigation
w Medical Certifier Name Title
G Tim Murphy Coroner
Address
52 Haviland Ave, Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Lake George
❑Burial I Date Cemetery or Crematory
❑Entombment July 13, 2011 Pine View Crematorium
Address
El Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address •
E Hold
N
O Date ' Point of
NTransportation Shipment
p` by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ' Registration Number
Name of Funeral Home Regan& Denny Funeral Home , 01443 _
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I-- Remains are Shipped, If Other than Above
E Address
Ce
w
a
Permission is hereby granted to dispose of the huma •r(7)
described abovv/e! a "ndicat d.
Date Issued 7 —/- ' - / ( Registrar of Vital Statistics 1 LIt, s -----..
(signature)
District Number ,�60�/ Place Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1-1-tl Place of Disposition {Pi-eU{ty C(wrcts'+L-
w (address)
W
CO
CZ (section) (lot num (grave number)
QName of Sexton or Per on in Charge Premises Al ic(if tilgli-
Z please print)
w
Signature Title CtthgiMa.,
(over)
DOH-1555(02/2004)