Brassart, John M1 _, ,
NEW YORK STATE DEPARTMENT OF HEALTP_ .
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John E . Brassart Male
Date of Death Age If Veteran of U.S. Armed Forces,
63 WarorDatesl0/11/1968-10/8/1971
p- Plate oVbeath Hospital, Institution or
Z City, Town or Village Street Address
illManner of Death 0 Natural Cause 0 Accident 0 Homicide Ei Suicide Undetermined 0 Pending
Iii Circumstances Investigation
W Medical Certifier Name Title
Address
113 Holland Ave . ,Alban* ,NY 12208
Death Certificate Filed District Number Register Number
>> City, Town or Village Albany 19 8 001
❑Burial Date Cemetery or Crematory
❑Entombment /-6 -// P/N j// t1 (_'�C/ �U2 y
Address C�?�. 'ASuet/(]Cremation
Date I Place Removed
Z Removal and/or Held
E ❑and/or Address
F-
Hold
O Date Point of
t
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander- Baker Funeral Home
Address 00035
M St. Warrensburg Nn 12i*
Name of unera irm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1/o ,'14 Registrar of Vital Statistics Janes Arrington
(signature)
District Number 198 Place DVANC 113 Holland Avenue, Albany, New York 12208
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k � � ]
I Date of Disposition ( /l Iy Place of Disposition 1t�/',,) 644,
2 (address)
Ili
I (section) lot S numbed. (grave number)
ci /' t !
Name of Sexton or Person - Charge of P emises 1hhl�
(please print)
Si nature Title Gaf Oe.,
9 �'
(over)
DOH-1555 (02/2004)