Brown, Bernard NEW YORK STATE DEPARTMENT OF HEALTH
11 # 7if)
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
t,1 Bernard Vincent Brown Male
= -= Date of Death Age If Veteran of U.S. Armed Forces,
March 31, 2015 78 War or Dates
:' Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
4
Manner of Death IL.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
". Medical Certifier Name Title
` Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
Death Certificate Filed District Numb Register N
City, Town or Village Fort Edward I g b r
14 ❑Burial Date Cemetery or Crematory
April 1, 2015 Pine View Crematory
❑Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal
and/or Held
and/or Hold
,i
Address
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
w
❑ Disinterment Date Cemetery Address
IllReinterment Date Cemetery Address
ix
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
r Address
A--' 82 Broadway, Fort Edward NY 12828
3_ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the huma ink describe aber a i icated.
Date Issued 4— (-1 5 Registrar of Vital Statistics V v
n �'�'�"' �—�/ (signatur)
iiirj(iTh
District Number 5 f 56 Place 15lAYA EJ�1.(, a.A-C(
r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
v) i Date of Disposition 04/01/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) if(lot number) (grave number)
Name of Sexton or Perso in Char a of Premises ►.. tit
(please print)
Signature Title (b $471W
(over)
DOH-1555 (02/2004)