Brehm, David NEW YORK STATE DEPARTMENT OF HEALTH 6b
Vital Records Section Burial - Transit Permit
R-- Name First Middle Last Sex
= David Martin Brehm Male
:` Date of Death Age If Veteran of U.S. Armed Forces,
August 15,2018 65 War or Dates
,_> Place of Death Hospital, Institution or
:° City, Town or Village Lake George Street Address 21 Pettis Street
Bal Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
la Circumstances Investigation
W Medical Certifier Name Title
Cl Charles Yun Dr.
Address
CR Wood Cancer Center, 102 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register�Number
City, Town or Village Lake George 5620 17
❑Burial Date Cemetery or Crematory
August 17, 2018 Pine View Crematory
❑Entombment Address
X❑Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
ti Remains are Shipped, If Other than Above
2: Address
Ix
ti.' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 8-16-18 Registrar of Vital Statistics alarm e.:613.
9 (signatur )
District Number 5620 Place Lake George,NY
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Qi n II Place of Disposition Emi,,,i 4-to tr..)
2 (address)
W
N
rx
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises ar.. 1. Sa+t*Ib1
Z (pleas print)
ui
Signature / Title
(over)
DOH-1555 (02/2004)