Gulbrandsen, Arne f t i 1497
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
oili Name First Middle Last Sex
Arne L. Gulbrandsen Male
Date of Death Age If Veteran of U.S. Armed Forces,
02 / 01 / 2016 88 War or Dates 1945-1947
}- Place of Death Hospital, Institution or
Z City, Town or Village Saratoga Springs Street Address 16 Jaipur Lane
0 Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide Ti Undetermined "—I Pending
Mt
CircumstancesInvestigation
iti Medical Certifier Name Title
Jama Peacock MD
' Address
Mil
VP 510 Geyser Rd
Death Certificate Filed District Number Register Number
y City,Town or Village Saratoga Springs 5 (fitLe
U Burial Date A Cemetery or Crematory
K�C / 8 Vi 5 , Pine View Crematory
uEntombmentiM Address
`<` giCremation Queensbury, NY
iiii4 Date Place Removed
Z❑Removal and/or Held
Itrk and/or Address
Hold
CA
03 Date Point of
Transportation Shipment
C by Common Destination
iiii Carrier
< '.El Disinterment Date Cemetery Address
Q Reinterment gli
Date Cemetery Address
Permit Issued to ; Registration Number
i> Name of Funeral Home Compassionate Funeral Care, Inc 00364
Address
402 Maple Ave., Saratoga Springs, NY 12866
<< Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
W
Permission is h reb granted to dispose of the human remains d scribed above as indicated.
isiiilliii:i Date Issued Registrar of Vital Statistics ( . -�}'(jt.anu0
(signature)
?< District Number ' 'D1 Place Saratoga Springs , New York
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 7
Date of Disposition 2 i�[+(, Place of Disposition e (At,/ (r e'stors .
2 (address)
tii
LE (section) if Qot number) C (grave number)
a Name of Sexton or Person in Charge Premises 5Ghr•,C
;Sfafvtt
•
(please pent) •
it Signature Ul Title WAiiVit.
(over)
DOH-1555 (02/2004)