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Bradley, Brian NEW YORK STATE DEPARTMENT OF HEALTH 4 2-1 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Brian Douglas Bradley Male Date of Death Age If Veteran of U.S. Armed Forces, January 13, 2017 46 War or Dates Il— Place of Death Hospital, Institution or W City, Town or Village Glens Falls Street Address Glens Falls Hospital W Manner of Death 1771 Natural Cause Accident Homicide El Suicide Undetermined 1--I Pending U CircumstancesInvestigation WC] Medical Certifier Name Title William Cleaver, M.D Address 100 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls ❑ Burial Date Cemetery or Crematory January 17, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z Removal and/or Held ▪ and/or Address H Hold CD Date Point of a. ❑Transportation Shipment CO by Common Destination d Carrier Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home- SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address X W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued /1/7/T 7 Registrar of Vital Statistics UN3 Gl,' TV--k,k; ).wAl - (signature) District Number Jr( 6/ Place (?.AAs• F' 1 )S //0),l • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 01/17/2017 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) W ft? Q (section) ,�/(lot number) (grave number) p Name of Sexton or Person in Charge of Premises L `jr.y ,r Jevtift W9 / (plse print) Signature 6/ Title C3Em11 ( (over) DOH-1555 (02/2004)