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Brown Sr., Wade
NEW YORK STATE DEPARTMENT OF HEALTI p; Vital Records Section ;.uriall c TransitPermit c..., -, - -..s..��:.- .....-,,x a x .,, ran..:.... 2 Name Firstwad e_ Middle soar r Last '"J`pW(l �C f Sex , # 1,:,:;.:. Date of Death ' 1 Age 1 If Veteran of U.S.Armed Forces, — 2 C)1?1J I� U2 1 War or Dates 1 Place Q?Death ns � ` Hospital, Institution or Mecu'�`_fht sonnsbi.trc � . 2 Ci'tyC ovviDar Village J o\ Street Address /go i , Mariner of Death 0Natural Cause, Accident ❑Homicide a Suicide ❑Undetermined L�Pending g� Circumstances Investigation i0 Medical Certifier Name Title ;C ti eC(y Coccv..o , C U(OCILC :_.. Address 1,?D1/4-1Q `t0. . a e_ LN \28 Li5 Death rtificate Filed District Number Register Number - City !ov or Village �c)"(ThSbU.ro� Cosh € Date i Cemetery o(remato • : ..�Guriai �'Z� 2-��� _ �Ih. v se-,LA) [ Ear ratio n4I Address Q���9r ( 4 QILQQ,- cc C I Date Place Removed t__? -er to"a# I ! and/or Held and/or ; Address 1 e Hold el I Date Point of 15-1_7 v-anspo�ation0 - Shipment ment.3 Common f Destination I Carrier "ILi uisinterment Date• i Cemetery Address t F7e:, I Date I Cemetery Address arrne�t , i Permit issued to 1 Regisfi;ation Number -: Name , Funeral dome Baker Funeral Home 01130 11 Lafayette St., Queensbury, NY 12804 i Naxie of Funeral Firm Making Disposition or to Whom t-1 Re;nairs are Shipped, If Other than Above -- I (q Oa TA 5-- 146,,a(Ac_r.oe gc(1 (,,2-355 Permisslon is hereby vented to dispose of the ruder _ vernal a described bed above as indieat 1 ' ` bate issued � -�3- I © �egisRegistrar of Vital Statisticselk hect_ 1 (signature)(( District Number � Place ✓' �9��5 Y � -1 I eer vv t is the remains of the decedent identified above were disposed of in accordance with this permit on: l p lgI DEt'EG L Disposition `7"2-4-1 s) Place of Disposition p;A.,, 'tv C,fa.yha i v rY i (address) d M (section) (lot number) (grave number) Oi g ('l+►r�l S vifiS �, Name of Sexton or Person in Charge of Premises c)P� (please print) ey i Sion,^_=ure i Title C,iii,�g4cor (over) DOH-1555 (02/2004)