Hanna Sr, Douglas NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section e N. Burial - Transit Permit
Name First Middle Last Sex
Douglas Stephen Hanna Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
8/2 3/1 3 65 War or Dates
—
144 Place of Death 1 9 6� $
Hospital, Institution or
City, Town or Village Argyle Street Address Pleasant valley, Route40 Argyle
1.t4Manner of Death®Natural Cause Q Accident El Homicide El Suicide � Undetermined �Pending
Circumstances Investigation
iti Medical Certifier Name Title
Edit Masaba MD
Address
1134 State Route 29, Greenwich, NY 12834
< Death Certificate Filed District Number Register Number
City, Town or Village Argyle 5750 d.3
<`'❑Burial Date Cemetery or Crematory
A0Entombment Address�/26/13 Pine View Crematory
[]Cremation Quaker Road, Queen 3bu r y
Eil Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
it—Transportation Shipment
i by Common Destination
im Carrier
[]Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
'< Name of Funeral Home P.B. Kilmer Funeral Home 01 077
Address
123 Main St. Argyle, NY 12809
iiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tle
Permission is hereby granted to dispose of the huma mains descrtbAA a ove as indicated.
Date Issued 8/2 6/1 3 Registrar of Vital Statistics _
A (signature)
MI District Number 5750 Place Argyle, NY U
.;<' I certify that the remains of the decedent identified above we disposed of in accordance with this permit on;
k:
W Date of Disposition kg 6,8 Place of Disposition /,vim V,1„...-N..., v0,44.f- ,
(a dress)
kti
VI
CC (section) (Jot ber) (grave number)
i
la Name of Sexton or ers n in r e of Premises � (1.j/4,C/
2 / / /1 (please print)
fgg Signature c Title 1 � �j1IC ,7
(over)
DOH-1555 (02/2004) •