Persons, Bradley NEW YORK STATE DEPARTMENT OF HEALTH `' l 711?
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Bradley C. Persons Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 26,2014 73 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Warrensburg Street Address 128 River Street
Alt
Il Manner of Death X Natural Cause I Accident I 'Homicide Suicide Undetermined Pending
AUi Circumstances Investigation
Medical Certifier Name Title
' z Suzanne Bergin MD
Address
3767 Main Street,Warrensburg,NY 12885
c , Death Certificate Filed District Number Register Number
k e
City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
December 4,2014 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z — Removal and/or Held
and/or Address
H Hold
ca
O Date Point of
co Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
p;, 3809 Main Street, Warrensburg,NY 12885
'E Name of Funeral Firm Making Disposition or to Whom
°F Remains are Shipped, If Other than Above
` . Address
#L.> Permission is he eby granted to dispose of the human r 'ns des ibed above as indicated.
Date Issued La / /1 4 Registrar of Vital Statistics A ....-t__AA-------)
(signature)
=e District Number,564 d Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
to Date of Disposition I 1 /$J ly Place of Disposition ati4sV4 aotra r 41,,
MI (address)
CO
Ce
0 (section) (lot number)
p Name of Sexton or Person in Charge of Premises 6rastpLii (grave number)
t✓w4
z (please print)
W4: _Signature Title C6Z ,I 1M
(over)
DOH-1555 (02/2004)