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Brown, Anthony 3 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Anthony Brown Male Date of Death Age If Veteran of U.S. Armed Forces, February 15, 2017 64 War or Dates Place of Death Hospital, Institution or W City, Town or Village Street Address 40 Northern Pine Road W Manner of Death FriNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title Ci Lance Hellman, Address 211 Church Street Saratoga Springs, NY 12866 Death Certificate Filed District Number (/C/ Register I'Pnber City, Town or Village ❑Burial Date Cemetery or Crematory February 17, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held • and/or Address N Hold Date Point of O ❑Transportation Shipment • by Common Destination p Carrier Date Cemetery Address ❑ Disinterment ❑ Reinterment 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 W d- Permission is hereby granted to dispose of the human remai s described ab ve as indicated. Date Issued C'-/l! Registrar of Vital Statistics i ti4j �d l/ 41' r (signata e) District Number Place 7C/rW/2 *///,1 • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i 4 W Date of Disposition 02/�/2017 Place of Disposition Quaker Road Queensbury,NY 12804 , , '(f j_14,16/?ff76 (address) // W (section) (lot num ber) (grave number) Name of Sexton or Petsop in arge of Premises LA- 1j�4 r° sA (please print) W Signature , `,( �i � Title G7/V.f-71t-16r7 (over) DOH-1555 (02/2004)