Hubert, Doras ' b �
NEW YORK STATE DEPARTMENT OF HEALTH Burial Tr rlSl Permit
Vital Records Section
Name First Middle Last Sex
Doras Downey Hu ert F
Date of Death Age If Veteran of U.S. Armed Forces,
September 21,2016 94 War or Dates No
F,. Place of Death Hospital, Institution or
Z City, Town or Village Cohoes Street Address Eddy Village Green
W Manner of Death n Natural Cause I I Accident Homicide Suicide n Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
O Donald Jue MD
Address
101 Jordan Road North Greenbush,N.Y. 12180
Death Certificate Filed District Number Register Number
City, Town or Village Cohoes /OJ MO
❑Burial Date Cemetery or Crematory
9/22/16 Pine View Crematory
❑Entombment Address
Ill Cremation Queensbury, N.Y.
Date Place Removed
Z ❑Removal and/or Held
and/or Address
N Hold
N
0 Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I-- Remains are Shipped, If Other than Above
IAddress
W
M.
Permission is hereby granted to dispose of the human remain desc ' above as i dicated.
Date Issued 9/21/16 Registrar of Vital Statistics C 4
(sign t re)
District Number l0� Place ec/ifey__
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Z DispositionDisposition2 ! Q G/ r✓t yt
Date of _7�2''31 Place of ��''► U Lc,� �
W '� (address)
co
0 (section) �lot number)_ (grave number)
QName of Sexton Perso in Charge of Premises J s,. i,G- »-ati.e.
Z (please print)
Signature /- Title G r'e/144,d•—
(over)
DOH-1555(02/2004)