Karlan, Douglas P .��
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Douglas P.Karlan Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/13/2022 73 Years War or Dates
H
Place of Death • Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 12 Reservoir Drive,Queensbury Town,New York 12804
p Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
O William Borgos MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 175
Burial Date Cemetery,Crematory or Facility Name
11/16/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 El Removal Date Place Removed
and/or and/or Held
CO Hold Address
0
O. Date Point of
N Transportation Shipment
p by Common
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
}.. Remains are Shipped,If Other than Above
a Address
EC
W --- ---
Ct' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/15/2022 Registrar of Vital Statistics Caroline 2ui(legarde Barber(ECectronicalTy Signed)
(signature/
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition J/lll I ZL Place of Disposition t '—.
W (address/ C��1
IL
(section) lotnumber/ (grave number)
g f � , 1
Name of Sexton or Person in Charge of P es
z v//ease prm
W Signature Title (be PIA'
DOH-1555(07/18)p 1 of 2
6406
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#