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Passino, Brayden Michael gos NEW YORKSTATE DEPARTMENT OF HEALTH Burlap - Transit Permit Bureau of Vital Records Name First Middle Last Sex Brayden Michael Passino Male Date of Death Age If Veteran of U.S.Armed Forces, 12/03/2019 10 Years War or Dates F- Place of Death Hospital,Institution or City,Town or Village Queensbury Town Street Address 24 Glenwood Avenue,Queensbury Town,New York 12804 IZ Mannerof Death ©Natural Cause Accident Homicide Suicide Undetermined Pending V Medical Certifier Name Title Circumstances Investigation Lauren Weintraub MD Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 179 Burial Date Cemetery,Crematory or Facility Name 12/05/2019 Pine View Crematory Entombment Address 0 Cremation Queensbury,New York Donation Removal Date Place Removed and/or and/or Held Hold Address C1 Transportation Date Point of by Common Shipment Carrier Destination 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 Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom } Remains are Shipped,If Other than Above Address W a" Permission Is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/04/2019 Registrar of Vital Statistics CarohneTifdegarde Barber(ECectronicaffySigned) /signature/ District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition Z 15111 Place of Disposition l (�-f o r� (address) W Q (section) (lot n berl (grave number/ Name of Sexton or Person in Charge of Premisesn Z /please print W Signature Title 1"I Zl1 DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013130 Receipt Human remains of _ r + � ' delivered on % , 20 '1 r G i i Pine View Cemetery Representing the funeral home named gnAwr,al permit Official Funeral Directors Reg.or License# ' `'