Emery, Douglas R NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Douglas R Emery Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 02,2023 War or Dates 1/3/1966-8/4/1976
Place of Death Hospital, Institution or
City, Town or Village Albany Street Address DVAMC 113 Holland Avenue Albany, NY 12208
Manner of Death®Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Carly Feuerstein-Simon MD
• Address
113 Holland Avenue Albany,NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village Albany 0198 069
❑Burial Date Cemetery or Crematory
11/03/2023 Pineview Crematory
❑Entombment Address
®Cremation Queensbury , NY
Date Place Removed
ry{❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Home Densmore Funeral Home, Inc. 0044 8
Address 7 Sherman Ave, Corinth, NY 1 282 2
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the hu •apv ins • - :cribed above as indicated.
Date Issued November 02,2023 Registrar of Vital Statisf' '- " H. rin•i .•
(signature)
District Number 0198 Place DVAMC, 113 Holland Avenue, Albany,New York 12208
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /A L/-ZvZ3 Place of Disposition 6', ,r e y,c 1,0 C/-GmR,
(address)
(section) (lot number) (grave number)
Name of Sexton or Perso ' Ch rgeof Premises K'ig/No4dtt 1)69A
(please print)
Signature let Title
(over)
DOH-1555(02/2004)
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#