Newcomb, Douglas r
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section r . ti Burial - Transit Permit `�S
1 Name First Middle Last Sex
Douglas Herman Newcomb male
Date of Death Age If Veteran of U.S. Armed Forces,
Feb. 18, 2015 90 War or Dates ±943-45
• Place of Death Hospital, Institution or
• City, Towocsaatilignx Glens Falls Street Address Glens Falls Hqs 'ta"
O Manner of Death,�xl Undetermm�c Pending
-L.J Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑
W' Circumstances Investigation
U.
.I Medical Certifier Name Title
Jennifer Donovan, MD
Address
Glens Fal]s, Nv
x. 6
1 Death Certificate Filed District Number I Register Number 1.
-70
City, T v �6 ggx Glens Falls 5601
❑Burial Date Cemetery or Crematory
FPb 20, 2015 Pine View Crematorium
❑Entombment Address
[ Cremation to of Queensbury, NY
Date Place Removed
❑ Removal and/or Held
and/or Address
a, Hold
Date Point of
❑Transportation Shipment
by Common Destination
'ea Carrier
tt
❑ Disinterment Date Cemetery Address
El Reinterment
Date Cemetery Address
• Permit Issued to Registration Number
°" Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
68 Main St. , Hudson Falls, NY
." Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
„I Permission is hereby granted to dispose of the human remains described abov a d' .
,,—'Re istrar of Vital Statistics �
Date Issued 4 ZU Zoi 9 /�� ��'�
/ (signature)
�`'• District Number 5601 Place City of Glens Falls, NY
sr
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Z /Mie- Place of Disposition :ru11/� 6.cf�.
address)
(section) of number) (grave number)
Name of Sexton or Person ' Ch ge of Premises Ara LV�J J
(pieaae print)
UP Signature Title liev4iwirk
(over)
DOH-1555 (02/2004)