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Christman, Douglas Lee NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Douglas Lee Christman Male Date of Death Age If Veteran of U.S.Armed Forces, 01/30/2024 51 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address 14 Madison Street Apt.2, Glens Falls, New York 12801 'p Manner of Death ❑X Natural Cause jilAccident Homicide Suicide Undetermined Pending Circumstances Investigation C.) Medical Certifier Name Title 0 Nicole Warren NP Address 9 Carey Road,Queensbury Town, New York 12804 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 65 Burial Date Cemetery,Crematory or Facility Name 02/02/2024 Pine View Crematorium _Entombment Address ©Cremation Queensbury Town,New York Donation ❑Removal Date Place Removed and/or and/or Held H Hold Address 0 d. Date Point of (I)El Transportation p by Common Shipment Carrier Destination IIIDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/01/2024 Registrar of Vital Statistics Megan Notin(ECectronica1ty 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: W Date of Disposition -2e 2/ Place of Disposition ‘JL� 2 (address) W (section) (lot number) (grave number) gName of Sexton or Person in Charge of Premises — f- ,/' &Zecfj Z (please print) W Signature Title e %z-`Tti't+ DOH-1555(07/18)p 1 of 2 1 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#.