Brown, Theodore i
4 NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iiia Name First Middle Last Sex
Theodore Harold Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
N. June 15, 1994 53 War or Dates Hone
Place of Death Hospital, Institution or
City, Trpwit Rix\iiikoalens Falls Street Address Glens Falls Hospital
1 Manner of Deathr. Natural Cause El Accident 0 Homicide D Suicide riUndetermined Pending
Circumstances Investigation
Medical Certifier Name Title
1 Orlando Martel.. MD
illiii Address
g0 South Glens Falls, NY 12839
Death Certificate Filed District Number Register Number
NI City, TRY(151RrAikclUx Glens Falls . NY 5601 8/
,�E� Date Cemetery or Crematory
IJ Burial June 17, 1994' Pine View Cemetery
Address
❑Cremation Tn of Queensbury, NY
gDate Place Removed
(2.❑Removal and/or Held
and/or Address
Hold
0 Date Point of
Q Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiiiiiii Permit Issued to Registration Number
€€` Name of Funeral Horrrleton Funeral Home a Inc. 00310
i:iiAddress
P.O. Box 67, 68 Hain St., Hudson Falls, N.Y. 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
M
i
jjg Permission is hereby/ granted to dispose of the human remains described above as indicated.
mi Date issued ta//(P� Registrar of vital Statistics= � ., 1Oiiiiiii �
/! (signature)
District Number 5601 Place City of Glens Falls , NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
la Date of Disposition 6/17/94 Place of Disposition Pine View Cemetery Queensbury NY 12804
2 (address)
cn Mohawk 102 5
CC (section) (lot number) (grave number)
AName of Sext or Person in Charge of Premises Rodney G C. Moshe r
(please print)
iL Signature 4ti4.r " ,,-v Title Supt .
DOH-1555 (10/89) p. 1 of 2 VS-61