Snowball, Douglas A # 139
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Douglas A.Snowball Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/06/2023 79 Years War or Dates 1964-66 1976-94
Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
IW W Manner of Death n Natural Cause Accident I 1 Homicide nSuicide Undetermined El Pending
U Circumstances Investigation
W Medical Certifier Name Title
John Quaresima MD
Address
319 Broadway, Fort Edward Town, New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 17
Burial Date Cemetery,Crematory or Facility Name
02/09/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town, New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
t/?
0
o- Date Point of
M Transportation
p by Common Shipment
Carrier Destination
o
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
$ Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/06/2023 Registrar of Vital Statistics Aimee L Mahoney(Electronically Signed)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
Z Date of Disposition Z J i 113 Place of Disposition 6,1.__
2 (address
W
CC CC (section) (tot Dumber) (grave number)
O• Name of Sexton or Person in Charge of Pre 's " S4t
(pll se print)
Z l t6 Or LU Signature Title
DOH-1555(07/18)p t of 2
•
,1 1. 6
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#