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Norman, Brian W YORK STATE DEPARTMENT OF HEALTH. ir S5� r , ital Records Section Name First Burial - Transit Permit Middle Last Sex Brian Joseph Norman Male Date of Death Age If Veteran of U.S. Armed Forces, July 3, 2018 63 War or Dates urPlace of Death Hospital, Institution or City, Town or Village Queensbury Street Address 10 Sherwood Drivw Cr Manner of Death❑Natural Cause ❑ Accident ❑ Homicide ElSuicide 0 Undetermined ❑ Pending LiLk Circumstances Investigation Medical Certifier Name Title Timothy M phy, Ad ess Haviland Ave Glens Falls, NY 12801 Death,C cate File District Number ister Number City, Town r Village �� (9 ) ❑Burial Date Cemetery or Crematory July 9, 2018 Pine View Crematorium ❑Entombment Address ,,©Cremation Quaker Road Queensbury,NY 12804 t. Date Place Removed ❑ and/or al and/or Held ,, Hold Address H Vi Date Point of cL! Li Transportation Shipment 0) by Common Destination a Carrier it Disinterment Date Cemetery Address z, Reinterment Date Cemetery Address if Permit Issued to Registration Number i-Ft Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 • N• ame of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address Imo,=. L`- 114P• ermission is here y granted to dispose of the human re ai s describec�stpo�ye as indicated. Date Issued 1 Registrar of Vital Statistics ` C ( fL-� signature) ;e District NumbeRl,9 S .Th CD �Place � r--% CrC nk--c-e-e---rN ,L • I certify that the remains of the decedent identified above were disposed of in accord-• ith this permit on: w Date of Disposition 07/09/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) Lli i (section) ,1(lot number (grave number) Name of Sexton or Person in Charge of Pre ises C Anr L . a^..1tt 2" (pl se print) 14 S• ignature 11 Title rittAtrot_ (over) DOH-1555 (02/2004)