Brown, Arthur NEW YORK STATE DEPARTMENT OF HEALTH
Z1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Arthur M. Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 1,2012 94 War or Dates World War II
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
0 Daniel Sooriabalan MD
Address
Glens Falls Hospital
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 nu)
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❑Burial Date Cemetery or Crematory
❑Entombment May 3,2012 Pine View Crematory
Address
❑X Cremation 21 Quaker Rd.,Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held •
and/or Address
Hold
U)
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5-2-12 Registrar of Vital Statistics [J3 ,
(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:
W Date of Disposition S13(IL Place of Disposition ,w u-, Cusvi torit--
w (address)
W
U)
(section) (lot numbp) (grave number)
Op Name of Sexton or Person in Charge f Premises t, twi
(please print)
W
Signature % Title COL PorTot
s
(over)
DOH-1555 (02/2004)