Zill, Douglas it
NEW YORK STATE DEPARTMENT OF HEALTIluir
3 "
Vital Records Section Burial - Transit Permit
Name First Middle L t Sex l
Douglas Gerald Last Male
>i Date of Death Age If Veteran of U.S. Armed Forces,
07/20/2012 74 years War or Dates 1956-1963
i Place of Death Hospital, Institution or
CVAXXown or VXIX#CX Colonie Street Address Albany County Nursing Home
tU
tzi Manner of Death latural Cause El Accident El Homicide El Suicide Undetermined ri Pending
Circumstances Investigation
to Medical Certifier Name Title
. Edgar C. Elum MD
AddAef8any County Nursing Home, Albany, NY 12211
Death Certificate Filed District Number Register Number
CX1(own or VX Colonie 153 144
Ri❑Burial Date Cemetery or Crematory
07/24/2012 Pine View Creamatory •
❑Entombment Address
'Cremation Queensbury, New York 12804
Date Place Removed •
Z Removal and/or Held
❑and/or Address
k Hold •
idei Date Point of
th Q Transportation Shipment
Et by Common Destination
Carrier
Q Disinterment Date Cemetery Address
-
'Li Reinterment
Date CEAcietery Address ^
Permit Issued to Regi tr n Number
Name of Funeral Home Maynard D. Baker �1 �
Address
11 La Fayette Street, Queensbury, New York-12804 -
> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ili
Permission is hereby granted to dispose of the human ains describe ab ye a
in is ted.
Date Issued 07/23/2012 Registrar of Vital Statistics „ , �✓�. p
(signature)
igi District Number 153 Place Colonie
i-- I certify that the remains of the decedent identifiecLabove were disposed of in accordance with t s-parrm� t on:
IU Date of Disposition 7^i — i- . Place of Disposition &.,UUAJ C�4,4 U—
N
(address)
CO
iX (section) (lot numbet}
(grave number)
6 Name of Sexton or Perso in Charg of Premises Zit r, \>*retr
Z (please print)
Signature Title CIZE61MItt
(over)
DOH-1555 (02/2004)