Brock, Douglas -II loll,
NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section OA11 1k7:0 Burial - Transit Permit
Name First Middle Last Sex
Douglas Earl Brock Male
- Date of Death Age `---- If Veteran of U.S. Armed Forces,
'u September 18, 2015 57 War or Dates
Place of Death Hospital, Institution or
City, Town or Village So. Glens Falls Street Address 129 Saratoga Avenue
Manner of Death Natural Cause ❑ Accident El Homicide El Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
.' Medical Certifier Name Title
' Noelle Stevens, M.D. Dr.
Address
100 Broad Street Glens Falls, NY 12801
- Death Certificate Filed District Number Register Number
City, Town or Village So. Glens Falls
V ❑Burial Date Cemetery or Crematory
September 22, 2015 Pine View Crematory
iz ❑Entombment35*
Address
fa®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
x ❑ Removal and/or Held
`ems, and/or Address
Hold
Date Point of
• ❑Transportation Shipment
by Common Destination
Carrier
• v III Disinterment Date Cemetery Address
"tii❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
▪ Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
w 82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
isherebydispose of the human remain escribed above as i icated.
_tom Permission granted to p
/j2 j�5 Registrar of Vital Statistics
Date Issued 9 9
tt
O,* ` // /(signature)
• District Number "{12 � Place /I C� , � 1 �l,�t,� ; C1-/-4
=u„o-
=z I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/22/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
, '
. (section) A (lot number) (grave number)
y Name of Sexton or Person in Charge of Premises ` 4fw r �i.,
d
(please print)
• ' Signature6 Title " n-
(over)
DOH-1555 (02/2004)