Brown, Gregory . , 0 50g
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gregory Aaron Brown Male
g$ Date of Death Age If Veteran of U.S.Armed Forces,
i,_ 11/04/2018 70 Years War or Dates Vietnam
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death gri Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
Citytoe
Town or Village Glens Falls 5601 522
.. ' g
❑Burial Date Cemetery or Crematory
11/08/2018 Pine View Crematory
❑Entombment-, Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal.47 and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
a by Common Destination
IN Carrier
4 Date Cemetery Address
❑Disinterment
❑Reinterment Date Cemetery Address
� ` Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Ai` Address
fir 53 Quaker Rd,Queensbury,New York 12804
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 11/07/2018 Registrar of Vital Statistics Wv6ertA Curtis(E(ectronica((y Signed)
(signature)
District Number 5601 Place Glens Falls, New York
lh I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11/10$ Place of Disposition -?ti. ( 6
(address)
At
fn
(section) (lot numb (grave number)
gName of Sexton or Person in Charge of Premises fi ('HI
z (ease pnnt)
Si /J gnature I ,i__ Title (17,6 1L
(over)
DOH-1555 (02/2004)