Langdon, Edward NEW YORK STATE DEPARTMENT OF HEALTH 2 Y/ 0 L:
Vital Records Section Burial - Transit Permit
= Name First Middle Last Sex
itz
tt Edward J. Langdon Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/30/2017 52 War or Dates no
Place of Death Hospital, Institution or
City, Town or Village Lake Luzerne Street Address 1 47 Potash Rd.
Manner of Death L. Natural Cause El Accident 0 Homicide p Suicide riUndetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
`' N. Balasul Bramama M.D.
Address
Albany, NY
= Death Certificate Filed District Number Register Nur
City, Town or Village Lake Luzerne 5656
❑Burial Date Cemetery or Crematory
11 /2/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, NY
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
-:❑Transportation Shipment
by Common Destination
Carrier
tip- Disinterment Li
Date Cemetery Address
Reinterment Date Cemetery Address
_. Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Ds
-:: Address
24 Church St. , Lake Luzerne, NY 12846
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 huma re ins des bed o as indicate
eig Date Issued 1 1 /2/201 7 Registrar of Vital Statistic --,2/ /ri gie.k/72( gnat
District Number 5656 Place Town of Lake Luzerne
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition q I 310 Place of Disposition ,v L./
-`" (address)
(section) (lot numb (grave number)
CName of Sexton or Person in Charge of Premises h► �
/ ( ease pant)
Signature Title rg '
(over)
DOH-1555 (02/2004)