Brown, Mark NEW YORK STATE DEPARTMENT OF HEALTH t 4 T
Vital Records Section Burial - Transit Permit
Name FirstMark MiddleA wn SexMale
Date of Death Age If Veteran of U.S. Armed Forces,
09/05/2011 40 years War or Dates
t-- Place of Death Hospital, Institution o
City, TO NUNKO Saratoga Springs Street Address 20 Walworth Street
a Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined n Pending
LIJ Circumstances Investigation
tu Medical Certifier Name Tit e
p Michael Sikireca M. D.
Ad5Debsoad St Waterford N Y
Death Certificate Filed DistrigMumber Regigtyr Number
City, TdWkAX%NW Saratoga Springs
❑Burial Date Cem to or C emat r .
09/07/2011 Pln +iew�rema�oynum
iii 0 Entombment Address
[Cremation Queensbury N Y
Date Place Removed
-' ❑Removal and/or Held
and/or Address
.= Hold
fife
Date Point of
05❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Regis Number
Name of Funeral Home Densmore Funeral Home
Address
7 Sherman Ave, Corinth, New York 12822
• Name of Funeral Firm Making Disposition or to Whom
# Remains are Shipped, If Other than Above
a Address
iii
d` Permission is hereby granted to dispose of the human remains 'be above,es indicated.
T. -4-otamit
Date Issued 09/07/2011 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition R(ijii Place of Disposition U /n.V'Jia Cw►441 tie--
2 (address)
ILU
C (section) (lot n ber) (grave number)
0. Name of Sexton or Pers• in Charge of remises /hs p r -SO mr-'t
2 / (please print)
iLi Signature 'r Title Ceih')i -
(over)
DOH-1555 (02/2004)