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Douglas, Thomas R NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex Thomas R. Douglas Male .....................................................................:......... ..... :: :.... ............................ ..... Date of Death Age If Veteran of U.S.Armed Forces, JulY... .,.:1991.:...'. ..: 68.::..:.... War or Dates U .5..... 1ayy 1:942......:1.948. H ............................ Z Place of Death Hospital, Institution or Tow a Street Address W ...........Johnsburg..... ........... .:--. _...... .............4.Home.)::::.1.3....th.....Lake:.Rd.:::::.. . ........ W Manner of Death ® Natural Cause ❑ Accident ❑Homicide ❑ Suicideo Undetermined Pending Circumstances Investigation .... ................. ....... . . ....... ........ .......:: :. ..::.:: -: .... .. : Medical Certifier Name Title © Roberd W...:. Sponzo M.D. Address 90 South Street, Glens Falls, N.Y. 12801 .::..................:..: _. _ :......: .... ... Death Certificate Filed District Number Register Number ,Town 9CY Johnsburg 5655 Date Cemetery or Crematory ❑Burial July 19, 1991 Pine View Crematory . ..:........:. ....... . . . .... ... Cremation Address .. .. Queensburg, N.Y. 12804 Z Date Place Removed 0 ❑ Removal and/or Held H and/or Hold ...... ....:: ........ .... .. .. Address to 0-.....:... . .:.:........: ... ........:....::::: _.... a Date Point of cn ❑Transportation by Shipment In Common Carrier ....:.:.................................. .::::: Destination .:::: .... .::...... ......................................: : ❑ Disinterment Date Cemetery Address .. ...... --. . ❑ Reinterment Date Cemetery Address::: .............. Permit Issued to Registration Number Name of Funeral Firm Alexander - Baker Funeral Home 00012 .. ...: Address .... ... .... _ ....�..1.4..Main,St:., Warrensburg., :.N.Y...::1.2885 .... . ...... ... ... Name of Funeral Firm Making Disposition or to Whom g Remains are Shipped, If Other than Above ......... ..:: ............ ........................... ...:::::. W Address __ Permission is hereby granted to dispose of the human remains described above as indicated. » Date Issued 7/1 S/91 Registrar of Vital Statistics IAAIW� �?2, signature) District Number 5655 Place Town Clerk's Office,T/O Johnsburc�, NOrth Creeks N Y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ) n� -�2 W? Date of Disposition �/ : Place of Disposition � �� �.,J C� �/� /Q N, (address) w`` U` (section) (lot number) (grave number) cc p Name of Sexton o erson in C r e of Premi sled Z Vlease print) tu' 7 ', Signature Title DOH-1555 (10/89) p. 1 of 2 VS-61