Dougher, Thomas NEW YO STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
(" ' Name First Middle Last Sex
_ ,, T a .% L. Lb0s3�ne�
'< Date of Death I I Age I If Veteran of U.S. Armed Force . c
01 I( 201 LD 1 1 b I I War or Dates 1 W
Place of Death J I Hospital, Institution or
p 2 City, own •r Village (Doe e. by i Street Address 7 ‘ Su ri n,p,•ti (4.61
tz Manner of Death KNatural Cause 0 Accident 0 Homicide n Suicide fl Undetermined ri fl Pending
tt3 Circumstances Investigation
Medical Certifier Name Title
f �._,'(_gym f\CtJla��r Vie s C 0-5(\.
Address J
iiiii
\L Q\ C� u Q.0S-; �.J- j'�== �� c�l,_r /� J I 7-
>> Death C-rtificate Filed �istnct umber moister N mber
City, own • Village p_e-INS �.r� I 51, 1 aD
Date Cemetery or Cre atory
:: XBurial PI lib) 1 aoALD pine_ evi Crine.
':-=. Address
=: ❑Cremation GIveOher g%Oo.c). vr' i .NyiDate Plaque..e..Y1aNz
emoved 1
g C Removal ; and/or Held
-• and/orHold I Address
0
Q Date Point of
VJ E Transportation. Shipment •
fl by Common Destination
Carrier
Disinterment Date I Cemetery Address
•_`• n Reinterment Date Cemetery Address
. I - •
1
Permit Issued to 1 I Registration Number
: Name of Funeral Home J 14- v�i v a si _A tt' I 0 i/So
- Address Th
Address.
Lr L 1 L ; 61 i✓ ,�s L L{r z %�' ` /2 _ zi .
< � Name of Funeral F fm Making Disposition or to Whom -J 1 f
?1,31 Remains are Shipped. If Other than Above `
Address -
• :L
Permission is hereby granted to dispose of the human remains described above as indicated.
€! Date Issued I I i g ( a.01(0 Registrar of Vital Statistics 0-6A. - ...A. e..k,.
(signature)
>€> District Number S( �P) Place (U t t iI- S to /Y 4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition �/1 8/201 place of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
New Hudson 13A 1
tn
cr (section) (lot number) (grave number) •
OName of Sex n or Person-in Charge of Premises Connie .L. Goedert
Z (please print)
11 Signature ;'_,•f)61.E"we... - -- -a--vs Title Cemetery Superintendent
- (over)
DOH-1555 (9/98)