Brown, Stephen I 1 5111
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Stephen Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
.rr September 21, 2014 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 653 Bay Road
gi Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Paul Bachman
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 l tlj
Y. ❑Burial Date Cemetery or Crematory
September 23, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
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0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
K00. Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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Permission ishereby granted to dispose of the hum. - • ains desai t�=d • , •ve a 'ndicated.
Date Issued�l - — i 4' Registrar of Vital Statistic
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition Qil'ik Place of Disposition "P,t,,,', (,.o.V--
2 (address)
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0 (section) (lot number)r (grave number)
QName of Sexton or Person in Charge of Premises jr, t•
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Signature 4 Title C1.71it
(over)
DOH-1555(02/2004)
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