Brewster, Wayne NEW YORK STATE DEPARTMENT OF HEALTH , Z i'l
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Wayne E. Brewster Male
Date of Death Age If Veteran of U.S. Armed Forces,
, March 16,2016 51 War or Dates
Place of Death Hospital, Institution or
Z' City, Town or Village T/O Johnsburg Street Address 3264 State Route 8
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
tiji Medical Certifier Name Title
Michael Sikirica MD
Address
,°`,50 Broad St.,Waterford,NY 12188
Death Certificate Filed District Number Register Number
J City, Town or Village T/O Johnsburg 5655
❑Burial Date Cemetery or Crematory
March 21,2016 Pine View Crematory
II Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal 0and/or Held
and/or Address
H Hold
CO
O Date Point of
O.
Transportation Shipment
a by Common Destination
Carrier
I_ I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
t, Name of Funeral Home Alexander-Baker Funeral Home 00037
,I Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
2 Address
it
tii.
Permission is hereby granted to dispose of the human m ' s described e as indica d.
`--'\
Date Issued '3' Q)- )�1 tegistrar of Vital Statistics 0
(signature) /
District Number 5655 Place T/O Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3)ZNJ/6 Place of Disposition KS4/ (.r atA,
2 (address)
W
Cl)
CL (section) (lot numbpr) (grave number)
Q Name of Sexton or Person in Charge of Premises lh��- eof*
Z 1 (please print)
W Signature 0 -; (( Title ( W Pt
(over)
DOH-1555 (02/2004)