Hall, Douglas NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
r Name First Middle Last Sex
Douglas J. Hall Male
o: Date of Death Age If Veteran of U.S. Armed Forces,
`: .
;;.;o August 30,2014 65 War or Dates ki,
1 Place of Death Hospital, Institutio diian River Rehab & Health Care
City, Town or Village Granville Street Address Center. Inc.
Manner of Death I X]Natural Cause Accident I 'Homicide i- 1 Suicide Undetermined Pending
Circumstances Investigation
1 Medical Certifier Name Title
:g::
Address
• Death Certificate Filed District Number Register N mber
▪�_▪_ City, Town or Village Granville 7, ,� �'
..0 Burial Date Cemetery or Crematory
09/03/2014 Pine View Crematory
❑Entombment Address
C Cremation
Date Place Removed
Z Removal and/or Held
and/or Address
F- Hold
CO
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
....: Permit Issued to Registration Number
%.:: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
:;f; Address
407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
P " Remains are Shipped, If Other than Above
IAddress ;/
4• :.. Permission is hereby granted to dispose of the human rema' s des ' d a e as indicated.
`e'�`� Date Issued ��P.�3 /� Registrar of Vital Statistics
:.;'.;. (signature)
District Number S�I(2 5� Place Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1/,fty Place of Disposition Eng,.J C. oE_
W (address)
U)
O (section) di(let number (grave number)
pName of Sexton or Person in Charge of Premises G 4''' Jo«rgia
Z (pljase print)
Signature C4— Title ClCPl!'012
(over)
DOH-1555(02/2004)