Douglas, Neil Edward /' # **---)
NEW YORK STATE DEPARTMENT OF HEALTH -^' Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Neil Edward Douglas Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/18/2023 82 Years War or Dates 1959-1963
F— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
LIJ
p Manner of Death E1 Natural Cause Accident EI Homicide Suicide Undetermined riPending
W Circumstances Investigation
WMedical Certifier Name Title
p Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 37
ElBurial Date Cemetery,Crematory or Facility Name
01/19/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
NHold Address
01 Transportation Date Point of
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
2 Address
CC
W
tL' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/19/2023 Registrar of Vital Statistics Megan No(in(ECectronicatry 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:
Z Date of Disposition /7J-ZQZ3 Place of Disposition P ,J(- Oe„c) (i-C-flii-ha 1-{,
2 (address)
W
CoCC (sip) (!at number) (grave number)
0 Name of Sexton or Person in Charge of P miss ' �I��^�� deli ci
Z (please print)
tU Signature � Title ti% Y
DOH-1555(o7/18)p 1 of 2
01 614
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#-