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Douillard, Gergory NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Sectigi Burial - Transit Permit . Name First Middle Last Sex Gregory. Ryan Douillard Male Date of Death A If Veteran of U.S. Armed Forces, January 3, 2016 13 War or Dates tPlace of Death Hospital, Institution or uf City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending ift, Circumstances Investigation Ili Medical Certifier Npme Title a J e-eek et (oornk,,r it-I, _ Address S?2> 61? k1 l (�S'11�y /Z t D h Certificate Filed District Number Register Number _,-= City, Village (�--JtoN,j' //r 5601 / urial Date Cemetery or Crematory =` January 5, 2016 Pine View Crematorium :❑Entombment Address _ _©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed j❑ Removal and/or Held ,a and/or Address E Hold CO Date Point of a. ❑Transportation Shipment 0). by Common Destination Carrier ElDisinterment Date Cemetery Address Date Cemetery Address III Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 . Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address CC d'- Permission is hereby ranted to dispose of the human remains descri a ve in d. Date Issued 020 6 Registrar of Vital Statistics (signature) District Number 5601 Place 64 f¢if /Jy/ / ' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: at Date of Disposition Place of Disposition Quaker Road Queensbury,NY 12804 (address) W co ce (section) (lot number) (grave number) G: Name of Sexton or P son in arge of Premises u �r �� '42 -he_ (please print) 111 Signature Title e.-rra-r G� (over) DOH-1555 (02/2004)