Brown, Russell NEW YORK STATE DEPARTMENT OF HEALTH OLO
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Russell Eugene Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 26, 2017 85 War or Dates
F. Place of Death Hospital, Institution or
W• City, Town or Village Moreau Street Address Home Of The Good Shepard
• Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
David Cunningham
Address
3 Irongate Center, Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Moreau 4562
❑Burial Date Cemetery or Crematory
February 28, 2017 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
▪ Hold
N
O Date Point of
NI I Transportation Shipment
s by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
2 Address
CL
W
a
Permission is hereby granted to dispose of the human remains described above as indicated.
s c//
Date Issued /2c )J7 �� �
Registrar of Vital Statistics 4
(signature)
District Number 4562 Place Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
illDate of Disposition 3J ,I r Place of Disposition �`,1,�r:.� Ciwr,cii cr-:G•t.
(address)
W
N
(section) / (lot number) (grave number)
pName of Sexton or Person in Charge of Premises �/‘r, �.,«` SG',.�1 it
Z (pl ase print)
ILI
Signature Title fl; /tI AL
(over)
DOH-1555(02/2004)