Brown, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
rrf::: Name First Middle Last Sex
r Kenneth Brown Male
% Date of Death Age If Veteran of U.S. Armed Forces,
a; September 6 2016
; P 39 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 44 First Street Apt B
Manner of Death C Medical Certifier Name
Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Title
,.r Dr John Stoutenberg,MD
Address
` �Glens Falls,NY
$k r N
a1 Death Certificate Filed District Number Register r
:, : City, Town or Village Glens Falls,NY 5601 -C
El Burial Date Cemetery or Crematory
❑Entombment September 9,2016 St. Alphonsus Cemetery
Address
El Cremation Pine Street, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
O. Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
?j Permit Issued to Registration Number
`f;.� Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
:X 407 Bay Road, Queensbury,NY 12804
i:.• .: Name of Funeral Firm Making Disposition or to Whom
I•-� Remains are Shipped, If Other than Above
Address
:"r:; Permission is hereby granted to dispose of the human remains described above as indicated.
,;r::
:▪ti: Date Issued 9 / g1/6 Registrar of Vital Statistics � . .�•yiZ C��
(signature
District Number J Li Cl j Place U
I certify that the remain oe decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition /q,// Place of Disposition a. 4 kA6,`j�.S ‘411,--5.
LU �� (ad�1{ess)
,ncS:cCL
of
a
(section) ter ber) (grave number)
p Name of Sexton or Person in Charge of Premises .
W (please print)
Signature Title
(over)
DOH-1555(02/2004)