Brown, Donald i ... 4 In
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Y Name First Middle Last Sex
Donald G.Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/12/2018 77 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
g" 5755 75
City, Town or Village Fort Edward
❑Burial
Date Cemetery or Crematory
1: 12/13/2018 Pine View Crematory
❑Entombment ,
Address
®Cremation Queensbury, New York
' ' Date Place Removed
-1❑Removal and/or Held
and/or Address
Hold
A 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 Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay 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 12/13/2018 Registrar of Vital Statistics Aimee Mahoney(Et ctronicaf(ySigned)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 17113 fig Place of Disposition • ii V lcl0rti.,
(address)
(section) (lot number) c (grave number)
• 1 Name of Sexton or Person in Charge Premises �r;tpt t �.J9.444
(please print) S
„ Signature Title /14 —Iry`_
(over)
DOH-1555(02/2004)