Brooks, Patsy 41- 35,E
NEW YORK STATE DEPARTMENT OF HEALTH" Burial - Transit Permit
Vital Records Section J -
Name First Middle Last Sex
Patsy J. Brooks Male
Date of Death Age If Veteran of U.S.Armed Forces,
July 8,2012 69 War or Dates Vietnam
i_ Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address 21 Sanford Street
'p Manner of Death IXi Natural Cause 'Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
GMedical Certifier Name Title
Gary Scidmore Coroner
Address
6930 State Rt.8,Brant Lake,NY 12815
Death Certificate Filed District Number Registumber
City, Town or Village T/O Warrensburg 5660
LI Burial Date Cemetery or Crematory
July 11,2012 Pine View Crematory
El Entombment Address
1J Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
OZ ] I Removal and/or Held
and/or Address
F" Hold
N
0 Date Point of
N 1 1 Transportation Shipment
p by Common Destination
Carrier
]Disinterment Date Cemetery Address
1
f Renterment 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
E Address
fY
W
O.
Permission is hereby granted to dispose of the human re i escribe bove as indicated.
Date Issued 7-11-12 Registrar of Vital Statistics e m A----9
(signature)
District Number 5660 Place T/O Warrensburg
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition )-11-I Z Place of Disposition frottlky Ct of iu w
W (address)
Cl)
0 (section) � (lot number) (grave number)
Za Name of Sexton or Person in Charge o remises r,$t Ear JINN�
w (please print)
Signature Title Clam yi..6(1.
(over)
DOH-1555(02/2004)