Brown, Jerry NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
fi Jerry Paul Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/27/2017 73 Years War or Dates
.1Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death
±` 0 Natural Cause ❑Accident ❑Homicide 0 Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Nicholas Kondo MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
city, Town or Village Saratoga Springs 4501 604
®Burial Date Cemetery or Crematory
12/01/2017 Pine View Cemetery
❑Entombment Address
Cremation QueensburyTown, New York
FP
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
I❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
0 Address
1
li Permission is hereby granted to dispose of the human remains described above as indicated.
{" Date issued 11/30/2017 Registrar of Vital Statistics jokn(P'Franck cE1 ctronical4Signed-
Y+'
a
4 (signature)
District Number Place
4501 Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
Signature Title
(over)
DOH-1555 (02/2004)