Dougherty, Kathleen Ablina 4G2
NEW YORK STATE DEPARTMENT OF HEALTH `' Burial - Transit Permit
Bureau of Vital Records
Name First Middle11N Last Sex
Kathleen Albina Dougherty Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/18/2022 90 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 14 Edgewood Drive,Queensbury Town,New York 12804
p Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Anne Evans DO
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 18
ElBurial Date Cemetery,Crematory or Facility Name
01/19/2022 Pine View Crematory
❑Entombment Address
ICremation Queensbury Town,New York
EIDonation
OZ Removal Date Place Removed
and/or and/or Held
H Hold Address
0
a Date Point of
co Li Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/19/2022 Registrar of Vital Statistics Caroline.7fiCdegaree Bar6er(E(ectronicafySigned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H /� ,
W Date of Disposition lit Ill Place of Disposition Ftqg
v}`.,")
2 address)
W
O (section) / +(!ot number) (grave number)
a Name of Sexton or Person in Charge of Pre ' es L/ (' Nna m
Z (phase print) `
W Signature Title l r"ii 472
DOH-1555(07/18)p 1 of 2
` .. ': b :3
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ; delivered on , 20r'
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# '"