Van Brunt, Paul NEW YORK STATE DEPARTMENT OF HEALTH x i ,S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Paul J. Van Brunt Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 7,2011 56 War or Dates
Place of Death Hospital, Institution or
Z: City, Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death Natural Cause X Accident [ I Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
Timothy E.Murphy Mr
Address
52 Haveland Ave.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 45 3
❑Burial Date Cemetery or Crematory
Entombment October 11,2011 Pine View Crematory
ill Address
0 Cremation Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
f" Hold
cn
0 Date Point of
N 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 00035
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
.2, Address
`IBC
iii
=aL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10)i zl[/ Registrar of Vital Statistics ("..)C_ . _ , lw
(sig ture)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p 17 t Place of Disposition Y �., 1 of r W Date of Disposition I �t I) p sition ��n. , rr�- o ,,.,_.
111
(address)
Cl)
W (section) (lot numb (grave number)
p it
Name of Sexton or Person in Charge Premises „1 ,, �.44
1 /J/fZ (please print)
Signature L. Title 02. 0A-1,-0Q.
(over)
DOH-1555 (02/2004)