O'Brien, Donald E 111 # ji
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
" 47 Name First Middle Last Sex
Donald W. O'Brien Male
MO
4.10 Date of Death Age If Veteran of U.S. Armed Forces,
1 /1 /2 01 8 82 War or Dates Vietnam
If Place of Death Hospital, Institution or
City, Town or Village Wilton Street Address 1 Woodlake Dr.
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
r Medical Certifier Name Title
tt
Address
Death Certificate Filed District Number Register Number
az City, Town or Village Wilton t
❑Burial Date Cemetery or Crema or
1 /2/2018 Pine View Crematory
Ri❑Entombment Address
®Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church St. , Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 0/-0�/,y Registrar of Vital Statistics Ava /,4 � 1 :"
r« (sign ire)
District Number 3--4'
Place br l// r U Y wl o f kidiftt
`7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
37 Date of Disposition Ohs Place of Disposition RAA,r 4 ar-."
(address)
+� (section) 4,,'
(lot number (grave number)
Name of Sexton or Person in Charge of Pre ises ,ab1/� ( lease prin
Signature �✓' Title fry iwL
(over)
DOH-1555 (02/2004)