Hallowell, Douglas A if g II
NEW YORK STATE DEPARTMENT OF HEALTH LF Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Douglas A.Hallowell Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/04/2022 56 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
IJJ
p Manner of Death []Natural Cause []Accident ❑Homicide Suicide FlUndetermined ri Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
0 Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 517
Burial Date Cemetery,Crematory or Facility Name
10/12/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
Date Place Removed
❑Removal and/or Held
— and/or
N
Hold Address
0
Date Point of
N ElTransportation Shipment
Q by Common
Carrier Destination
E
Disinterment
Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1. Remains are Shipped,If Other than Above
2 Address
CC
W
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/12/2022 Registrar of Vital Statistics Megan Nofin(ECectronicalTy Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition I/ Zp 2Z Place of Disposition f7,ylg_,;+ e,„A) Cr'vr+-4
11! (address)
W
(lotCO
CC number) (grave number)
(section) 1
a Name of Sexton or Person in har of Premises �JP" t 4 G� v+'�G"c�
Q / (please print)
a ,-.��
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Signature Title L��'""4 �
DO H-1555(07/18)p t of 2
3
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ,