Brown, Gary NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gary Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/30/2018 67 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
al Manner of Death w Natural Cause Accident Homicide �Suicide Undetermined Pending
tU Circumstances Investigation
w Medical Certifier Name Title
William Cleaver MD
v Address
100 Park St,Glens Falls,New York 12801
4-1
Death Certificate Filed District Number Register Number
City, Town or Village Glens Fails 5601 475
- Burial Date Cemetery or Crematory
, 10/09/2018 St.Aiphonsus Cemetery
0 Entombment Address
❑Cremation Queensbury Town, New York
--, Date Place Removed
Z ❑Removal and/or Held
0 and/or Address
H Hold
0
a Date Point of
a.
0 Transportation Shipment
1 by Common Destination
Carrier
1. Disinterment Date Cemetery Address
; Reinterment Date Cemetery Address
_p Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
S. Address
El
M. Permission is hereby granted to dispose of the human remains described above as Indicated.
Date Issued 10/05/2018 Registrar of Vital Statistics Ro5ert_ACurtis tEactronicalryy Signe
(signature)
District Number 5601 Place Glens Falls. New York
I, I certify that the remains of
the decedent identified above were disposed of in accordance with thispermit on:
P i - lylib Disposition57-, A Ipls�, c he `x1�
tU▪ Date of Disposition � Place of vea�r b, /
(add s)
111
VI s �.3 e1Z f
2it (s on) J'� 1 :(lot mber) (grave number)
, Name of Sexton or Person in Charge of Premises ! ' ram'" l��Zt't$_
(please print)
Signature Title
(over)
DOH-1555 (02/2004)