Stewart, Douglas ,,i r,i c utPARTMENT OF HEALTH
Vital Records Section F I. Burial - Transit Permit
Name First Middle Last Sex
Douglas Brian Stewart Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 16, 2012 45 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
ii;a Manner of Death a Natural Cause 0 Accident 0 Homicide 0 Suicide n Undetermined Pending
k
Circumstances Investigation
Medical Certifier Name Title
Timothy Murphy,
Address
52 Haviland Ave Glens Falls, NY 12801
Beath Certificate Filed t District Number Register Number
Cit Town or Village �j ,4Iv�.S � 1�S - 6 o i Z"
0 Burial Date Cemetery or Crematory
January 20, 2012 Pine View
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0 Removal
and/or Held
4 and/or Address
4* Hold Date Point of
CTransportation Shipment
by Common Destination
Carrier Date Cemetery Address
Disinterment
Reinterment
Date Cemetery Address
77
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Y:i Remains are Shipped, If Other than Above
Address
ermission is hereby granted to dispose of the human remains described above as P 1•Ciao
J Registrar of Vital Statistics
Date Issued ( � g Z (signature)
A C� l Place 6 S +G , \S
ga District Number�___
that the remains of the decedent identified above were disposed of in accordance with this permit on:
{ centi fy
Disposition 01/0/2012 Place of Disposition Quaker Road Queensbury,NY 12804
I Date of Dis p (address)
lot number)
(grave number)
(section) I „ �
ti f5 l'
Name of Sexton or Pelson in Charg
of Premises (please print)
7 Title
Signature
(over)
DOH-1555(02/2004)