Brown, Ralph NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit tit
°°' Name First Middle Last Sex
Ralph Paul Brown Male
. Date of Death Age If Veteran of U.S. Armed Forces,
p,n} July 10,2016 63 War or Dates
Place of Death Hospital, Institution or
Z. City, Town or Village Bolton Street Address 919 Trout Lake Road
n: Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
ILI Circumstances Investigation
Medical Certifier Name Title
John E.Lukaszewicz
$, Address
84 Broad St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Bolton 5650 UI
❑Burial Date Cemetery or Crematory
El Entombment July 12,2016 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
O Date Point of
yTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
a Permit Issued to Registration Number
`F Name of Funeral Home Alexander-Baker Funeral Home 00037
3r Address
: 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
tL
tr3.l —
, Permission is he eby ranted to dispose of the human remains descr ed ove as indicated.
r`
a Date Issued � /� /� Registrar of Vital Statistics � �,��^^''�
Y=§-41 i�
(signature)
3_ District Number50 PlaceQ(,jn C.) 0 1+0 f.-
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 71 13A Place of Disposition /F,uVtt..s 47.4....etort‘...,
2 (address)
W
U)
Ce (section) /� (lot number) ( (grave number)
pName of Sexton or Person in Charge o Premises 6hPi JQqreis
'Z /� i (please print)
Signature l...t Title azEntiik
(over)
DOH-1555 (02/2004)