Brown, Timothy /0OI
NEW YORK STATE DEPARTMEtIT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
' Timothy Morgan Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
xt 12/15/2018 54 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Brant Lake Street Address Deceased's Residence
Manner of Death Lu Natural Cause Accident El Homicide ri Suicide riUndetermined 17 Pending
Circumstances Investigation
19, Medical Certifier Nar ` p-Ozp 7.:_e
Title
,',,, Address 1-- -
''' , /74' ; 'i 1/- /A/1 '4 . .7./,? pc3
Death Certificate Filed District Number Register Number
-, City, Town or Village YI Co V � S24 q
❑Burial Date Geffitery or r mato
❑Entombment 12/17/2018 ,ins /-ea. C�.�'/..a../Otr(lsvi
Address
•
fr ®Cremation C1 veiC 4e Stt-ee -c- U� ,,, f/y/i �v-
ke
Date Place Removed
Removal and/or Held
. and/or
Address
Hold
Date Point of
" Transportation Shipment
II by Common Destination
Carrier
Disinterment Date Cemetery Address
-
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
u p4; Address
'4,y1 9 Pine St/P.O. Box 455 Chestertown NY 12817
w,, Name of Funeral Firm Making Disposition or to Whom
ti Remains are Shipped, If Other than Above
1 Address
r y{ Permission is hereby granted to dispose of the human remains escribed above as i icated.
Date Issued a-/7'-/- Registrar of Vital Statistics
,; (signature)
° District Number 6,0}( Place 17;—, of r, N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition IIVO? I' Place of Disposition �,At V,t t, rep►(•ir,uri
, 111 (address)
(section) (lo}� umber) (grave number)
Name of Sexton or Person in Charge of Premises / ��`�° r` t4
Y�j s print)
Signature ?IL %�— Title �r try (pleare
(over)
DOH-1555 (02/2004)