Brown, Robert NEW YORK STATE DEPARTMENT OF HEALTH . 1 '9 I
Vital Records Section • Burial - transit Permit
Name First Middle Last Sex
Robert Brown M
Date of Death 1 0/2 8/2 01 5 Age 6 4 If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Glens Falls Hospital, Institution orGlens Falls Hos ital
City, Town or Village Street Address P
Manner of Death® Natural Cause ElAccident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical CertifierCt Name Eric Pillemer Title MD
Address 100 Park Street, Glens Falls,NY 12801
Death Certificate Filed Glens Falls District Number Register Number
City, Town or Village 5 60 J -5 3 C►
❑Burial Date 1 1 /02/201 5 Cemetery or Crematory Pine View Crematory
❑Entombment Address
[Cremation 21 Quaker Road, Queensbury,NY 12804
Date . Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
CO
Date Point of
-12. ❑Transportation Shipment
0 by Common Destination
O; Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Funeral Home 01 078
Address
136 Main Street, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
Address
LK
hiw
174a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 1 /2 Jib' Registrar of Vital Statistics k.AJ CAA,r,-q L.A)--
(signature)
District Number to 1 Place 6 ( ,, -NS VG.r\S , I" y
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition if hill' Place of Disposition .P„,,U,:,,., rnp c{or 16.mk
(address)
lif
(section) A (lot number) (grave number)
Name of Sexton or Person in Chargepf Premises ii rk.r. if-
4 p/ease print)
Signature �C Title
(over)
DOH-1555 (02/2004)