Skogsberg, Braylon NEW YORK STATE DEPARTMENT OF HE, i ti (
Vital Records Section Burial - Trani s ermit
Name First middle Last Sex
Brayton Parkes Skogsberg Male
Date of Death Age If Veteran of U.S. Armed Forces,
032011 0 years War or Dates
Place o/10/Death Hospital, Institution or
Z City, Street Address To w�g�fi�V Glens Falls Glens Fails Hospital
Manner�Oea h t Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
tLi. Circumstances Investigation
W Medical Certifier Name Title
;
Address tte Biss Cnm
90 South Street, Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, TokVa Glens Fails 5A01 2
❑Burial Date Cemetery or Crematory
:Ai ❑Entombment 03/14/2011 Pine View Crematorium
Address
inii 09remation QUeanshiiry, NY 12804
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
Cl)r Hold
0 Date Point of
d Transportation Elp Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sullivan-minahan & Potter Funeral Home, Inc. - 01695
Address
407 Bay Rd. Queensbury. Ny 12804
Name of Funeral Firm Making Disposition or to Whom
io Remains are Shipped, If Other than Above
Address
lu
"` Permission is hereby granted to dispose of the human remains de /r�ibeeddaa ov 'ndicated.
Date Issued 03/14/2011 Registrar of Vital Statistics � ,'L'•' h
(signature)
>` District Number Place
5601 Glens Falls
I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition -14-1I Place of Disposition i lht U;ir,) Cte^n.ct pt•,,;N
(address)
U,
re (section) 4 ,_
(lot numbb) (grave number)
a Name of Sexton or rson in Char a of Premises r•S r JAhsfr
(please print)
Signature +4--
Title Cl?Ell 8r0e,
(over)
DOH-1555 (02/2004)