Harvey Jr, Douglas NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section e
Name First Middle Last Sex
DouglasS Coate Harvey,`(r Male
Date of Death 1 Age If Veteran of U.S.Armed Forces,
12/21/2012 58 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Chestertown Street Address JceSi (.5-Aolp - bef"4"&)-7,4
W Manner of Death X❑Natural Cause Accident Homicide n Suicide n Undetermined ❑ Pending
Circumstances Investigation
WW Medical Certifier Name r
CI J, /,' � of/ ,4. e p tle
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Deat ificate Filed 0 District Number Register mbar
City, To n Village Q� �oLc le c- � ).,.
❑Burial Date for Crerrytoyy
0 Entombment 12/24/2012 '- .PGA( z6',s9 c�-,r -/v'L�
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Removal Date Place Removed
pz � and/or and/or Held
F Hold Address
t'n Date Point of
a. El Transportation Shipment
CO by Common Destination
El Carrier
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
1_ Remains are Shipped, If Other than Above
2 Address
W
a Permission is hereby granted to dispose of the human re a s d cri as i icated.
Date Issued /a/a i//z Registrar of Vital Statistics ,
(signa re)
District Number 0'6,o-' Place . zA
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11-l-t2 Place of Disposition Ra 0%,11..1 ertnc riu,
W (address)
CO
O (section) / (lot number) (grave number)
p Name of Sexton or Person in Charge of remises /`r0 ,� cç"A-
Z (phase print)
W Signature 4L- Title < Y4'i t
(over)
DOH-1555(02/20 4)'