Speicher, Douglas NEW YORK STATE DEPARTMENT OF HEALTH , I #. 5 1O
Vital Records Section Burial - Transitermit
Name First Middle Last Sex
Douglas 5 Speicher Male
. Date of Death Age If Veteran of U.S. Armed Forces,
• October 20, 2012 80 1 War or Dates
; Place of Death Hospital, Institution or
i City, Town or Village Queensbury Street Address 61 Cascade Court
ES Manner of Death X Natural Cause Accident Homicide Suicide n Undetermined ❑Pending
1 Circumstances Investigation
Medical Certifier Name Title
la Dr.Robert Sponzo,MD
Address
Glens Falls,NY
Death Certificate Filed District Number le aster Number
City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
October 23, 2012 Pine View Crematory
❑Entombment Address
Ii Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
9 and/or Address
H Hold
N
0 Date Point of
N ( I Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
_'. Name of Funeral Home Regan Denny Stafford Funeral Home 01443
• Address
53 Quaker Road Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
>k;.$ Remains are Shipped, If Other than Above
Address
IIf
W.
Permission is hereby granted to dispose of the human/re ains described above as indicated.
• Date Issued k C>l3 a0 Registrar of Vital Statistics • c..._
��
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ro-2y-tl, Place of Disposition 1',e.r1►c r, OCWr--
2 (address)
W
N
CC (section) lot number) (grave number)
pName of Sexton or Person in Charge of Premises �f,.i oe641—
Z
p ase print)
W
Signature g Title CQ,I/ZIMii-t 0L
(over)
DOH-1555(02/2004)