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Bradt, Darryl NEW YORK STATE DEPARTMENT OF HEALTH 'Vital Records Section Burial - Transit Permit Name First Middle Last Sex Darryl H. Bradt Male Date of Death Age If Veteran of U.S. Armed Forces, 12/1 4/201 7 83 War or Dates 1950 ' s f- Place of Death Hospital, Institution or W City, Town or Village Lake Luzerne Street Address 727 Ralph Road ct Manner of Death© Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑ Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title 0 William Tedesco M.D. Address Glens Falls, NY Death Certificate Filed District Number Register Number City, Town or Village Lake Luzerne 5656 l! ❑Burial Date Cemetery or Crematory 12/18/2017 Pine View Crematory ❑Entombment Address ®Cremation Queen ;bury, NY Date Place Removed Z ❑Removal and/or Held 0 and/or Address V} Hold 0 Date Point of CL El Transportation Shipment G by Common Destination Carrier ❑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 St. , Lake Luzerne, NY 12846 Name of Funeral Firm Making Disposition or to Whom Ih- Remains are Shipped, If Other than Above 2 Address mr W 1 CI. Permission is hereby granted to dispose of the human'rer ains described above as indicated. Date Issued /c � f/ 7 Registrar of Vital Statistic _ L� Vim- z� .()-4--"A"" . signature) / / g ) District Number 6/o, IX Place ///,2/. //// 7t---/-- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z � ,v W Date of Disposition gin I°d 1'11 Place of Disposition '{Atli, (�„P,,10r;.. - ram+ (address) W CO Ir (section) it(lot number) (grave number) pp Name of Sexton or Person in Charge f Premises /^P,- _)+.--1+ (ple se print) /+ Z i �M ' fl W IIr Signature Tr Title (over) DOH-1555 (02/2004)