Brown Jr, Lyle e_ ,,,.1t
NEW YORK STATE DEPARTMENT OF HEALTH # tg 7
Vital Records Section Burial - Transit Permit
Name First y1e Middle L� wn Jr. SexMale
Date of Death Age If Veteran of U.S. Armed Forces,
11/01/2014 86 years War or Dates
1 Place of Death Hospital, Institution or
City, Town or Village Town Of Milton Street Address Gateway House Of Peace
titManner of Death Q Natural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermined 0 Pending
Circumstances Investigation
ta Medical Certifier Name Title
Christopher Messitt Physician
Adftshorth Road, Wilton, Ny
Mii Death Certificate Filed District Number Register Number
blown or'� Milton 4561 47
❑Burial Date Cemetery or Crematory
11/03/2014 Pine View Crematory
❑Entombment Address
[Cremation Queensbury NY 12804
Date Place Removed
Removal and/or Held
and/or Address
1= Hold
tig
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Reg r tion Number
Name of Funeral Home Compassionate Funeral Care 00364
Address Maple Avenue, Saratoga Springs, Ny 12866
lqiiiii Name of Funeral Firm Making Disposition or to Whom
1#4 Remains are Shipped, If Other than Above
• Address
l
lI
Permission is hereby granted to dispose of the hum-n ains des Date Issued ' bove a ' di d.
11/03/2014 Registrar of Vital Statis 41 L.
Iiiii �� (signature)
Pi District Number 4561 Place Milton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI• Date of Disposition ///ti/III( Place of Disposition (41,.,
l (address)
tfl
CZ (section) (lot number)- (grave number)
a.
▪ Name of Sexton or Person i Charge of Premises .. 4_fi1 u
(please print)
ie Signature Title _ (IAve o'►
9C
(over)
DOH-1555 (02/2004)