Brown, Anthony - 'illi # ern
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
',:a Name First Middle Last Sex
'f Anthony P. Brown Male
s?f%` Date of Death Age If Veteran of U.S. Armed Forces,
>r rtr
>"f June 30,2014 73 War or Dates
;-I Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death I XI Natural Cause E Accident Homicide piSuicide ❑Undetermined n Pending
Circumstances Investigation
,m, —
Medical Certifier ; Name Title
1 V k\( \ )4\I I c F v- k
Address
3-e-fS �- ,-N\S R6-.
OA Death Certificate Filed 1 District Number Register Number
City, Town or Village Glens Falls,NY 5601 3O1
❑Burial Date Cemetery or Crematory
July 2, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
co
o Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Date Cemetery Address
ID Renterment
! 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
1''' Remains are Shipped, If Other than Above
Address
," Permission is hereby granted to dispose of the human remains des rjbe i/a}/Qeve dicated.
,, ' Date Issued 07O/ 2p1L/ Registrar of Vital Statistics i� �rC
Yf,y, (signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 7 2 .,
� -lti Place of Disposition i,t[)u ,
2 Clot
a tw_
ddress)
W
N
re (section) f (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises Uiuetctl. d
i401-
Z (pleasent)
W
Signature Title
(over)
DOH-1555(02/2004)