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Douglas, Brian Joseph NEW YORKSTATE DEPARTMENT OF HEALTH — _ i0.1. Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Brian Joseph Douglas Male Date of Death Age If Veteran of U.S.Armed Forces, 03/22/2023 71 Years War or Dates i,,,. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death El Natural Cause EAccident ❑Homicide Suicide ❑Undetermined Pending Circumstances Investigation W Medical Certifier Name Title C Asim Chaudry 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 160 RBurial Date Cemetery,Crematory or Facility Name 03/24/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation OZ❑Removal Date Place Removed and/or and/or Held H Hold Address N 2(q❑Transportation Date Point of Q by Common Shipment Carrier Destination Disinterment Date Cemetery Address EiReinterment 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 F- Remains are Shipped,If Other than Above a Address Ir W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/24/2023 Registrar of Vital Statistics Megan Wolin(Electronically 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 W Date of Disposition 3�� ?ZoL3 Place of Disposition tx)e 1 e,,) Cfr--in 2 (address W NCC (section/ (lotlumber) (grave number/ 8 Name of Sexton or Person in Charge of mises A7ort9.4) 1 cal Z (please print) RISignature j Title d Pe"" DOH-1555(o7/18)p 1 of 2 cpps ' + '� 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#