Briere, Roland €�7J LI
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
P6 Name First Middle Last Sex
11':.. Roland Joseph Briere Male
Date of Death Age If Veteran of U.S. Armed Forces,
_ 05/26/2018 54 Years War or Dates
#- Place of Death Hospital, Institution or
City, Town or Village Glens Fallsiiii Street Address Glens Falls Hospital
W0 Manner of Death j Natural Cause ❑Accident Homicide Suicide n Undetermined ri❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Michael Miles MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 268
0Burial Date Cemetery or Crematory
05/30/2018 Pine View Crematorium
1: ❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Removal and/or Held
Q and/or Address
N Hold
Date Point of
❑Transportation Shipment
C by Common Destination
ii Carrier
Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
i- Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
• ,= 68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
2 Address
t
W
et
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/29/2018 Registrar of Vital Statistics Iolerr.4 Curtis(ETctronic l ySigned)
(signature)
- ' District Number 5601 Place Glens Falls, New York
.- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition t/1 /14 Place of Disposition e.,,0.-, (4 a',
2 (address)
ILI
en
Cr (section) 7[(lot number) (grave number)
Name of Sexton or Person in Charge o Premises n L,
Z O'ease Tint)
LL[ Signature 4 Title (Df'"MU(
(over)
DOH-1555 (02/2004)