Mott, Bryan 1-/4/O
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section t _ ; Burial - Transit Permit
Name First Middle Last Sex
Bryan J. Mott Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 13,2016 53 War or Dates
Place of Death Hospital, Institution or
Z. City, Town or Village Glens Falls Street Address Glens Falls Hospital
oManner of Death X Natural Cause Accident 1 I Homicide Suicide Undetermined Pending
W Circumstances Investigation
AU Medical Certifier Name Title
0 Timothy E.Murphy Mr
Address
52 Haveland Ave.,Glens Falls,NY 12801
Death Certificate Filed District Number Reg Ni;mher
City, Town or Village 5601 1p
❑Burial Date Cemetery or Crematory
Entombment June 16,2016 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z — Removal and/or Held
and/or Address
H Hold
Cl)
0 I Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
7 Renterment 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
t-. Remains are Shipped, If Other than Above
r Address
111
IX,_ Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued . // / /t, Registrar of Vital Statistics ��
(sign
District Number 5 (Do/ Place 6., (kn.. S 0‘ 1, SI A,/ 5'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W (Date of Disposition (mill, Place of Disposition u � (w .)ço__
2 (address)
W
CO
CZ (section) J (ldt nun r) (grave number)
pName of Sexton or Person in Charge o Premises G/&o r L t.1491-
Z ii(please print)
W Signature Title CWAeg--
(over)
DOH-1555 (02/2004)