Brown, Edward It
NEW YORK STATE DEPARTMENT OF HEALTH ��-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edward Louis Brown i Male
Date of Death j Age ! If Veteran of U.S. Armed Forces,
May 28,2012 60 War or Dates Vietnam
. Place of Death i Hospital, Institution or
Z City, Town or Village City of Plattsburgh Street Address CVPH Medical Center
aManner of Death il +Natural Cause (X+Accident I 1 Homicide Suicide Undetermined Pending
Circumstances Investigation
GMedical Certifier Name Title
Deonarayan P. Saha MD
Address
75 Beekman Street,Plattsburgh,NY 12901
Death Certificate Filed I District Number Register Number
City, Town or Village City of Plattsburgh 901
❑Burial 1 Date Cemetery or Crematory
June 4,2012 Pine View Crematory
❑Entombment Address
El Cremation i Queensbury,NY
Date I Place Removed
ZZ I 1 Removal I ! and/or Held
and/or I Address -
H Hold
(/)
0 1 Date Point of
NI 'Transportation L Shipment
p by Common 1 Destination
Carrier
Disinterment Date i Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 1 Registration Number
Name of Funeral Home M. B. Clark,Inc. 01075
Address
2310 Saranac Ave.,Lake Placid,NY 12946
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
C4
W
a
Permission is hereby granted to dispose of the human remains describe boy as indic%atl��,d�.
Date Issued 05/30/2012 Registrar of Vital Statistics &A// (
signature)
District Number 901 Place City of Plattsburgh
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tuDate of Disposition 01(11 Place of Disposition �r'^+U' w Ct dfiur-
W (address)
cn
cr
0 (section) (lot number) (grave number)
ZName of Sexton or Per on in Charge of remises /j r 0144
W (please print)
Signature L Title Cpcil.t'0Cl..
(over)
DOH-1555(02/2004)