Brown, Larry NEW YORK STATE DEPARTMENT OF HEALTH mi
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Larry Jr. Brown Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. March 24, 2015 War or Dates No
2 Place of Death Hospital, Institution or
W City,Town, or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death fl Natural Cause 0 Accident ❑ Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Robert W, Sponzo MD
Address
Cancer Center, 102 Park Street, Glens Falls, New York 12801
Death Certificate Filed District Number /'O I Register Number
City,Town or Village Glens Falls 66
❑Burial Date Cemetery or Crematory
March 27, 2015 Pineview Crematorium
❑Entombment Address
n Cremation Quaker Road Queensbury, NY 12804
Z Date Place Removed
0 Ei Removal and/or Held
and/or Address
l' Hold
0 Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
5 El Disinterment
El
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
IAddress
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/2.6/ '5 Registrar of Vital Statistics W .
Cyr"l '(signature)
District Number 5 6o( Place Glens Falls,New York
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 03/27/2015 Place of Disposition Pineview Crematorium
2 (address)
to
Z0 (section) of� mber. (grave number)
2 Name of Sexton r in Charge of Premises 6�-p,a,Ai
(please print)
Signatur / Title �,'� f a�r!— I.
(over)
DOH-1555 (02/2004)