Long, John NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex Male
John R Long
Date of Death i Age If Veteran of U.S. Armed Forces,
4/14/2013 60 War or Dates 1972-1975
Place of Death __. Hospital, Institution or
City. -IVOCOCIMIlik Glens Falls ` Street Address Glens Falls Hospital
Manner of Death 1M Natural Cause �Accident �Homicide Suicide Undetermined Pending
rt. _ _ _ _ Circumstances Investigation l
IN Medical Certifsextie Na � _ Title
Address
1 CD Pa-r i< 'fit GjeAS P{1/_ /4 V 1 Z'8 o 1
-Death Certificate Filed District Number . Regist ber
City, t h Gr1Pnc Fallc 5601 �c J6
Date Cemetery or Crematory
❑Burial i 4/16/2013 Pine View Crematory
Address
OC rem ationi Queensbury,NY
Date Place Removed
QRemoval and/or Held
and/or Address
or Hold
Date Point of
OS Q Transportation Shipment
a by Common Destination
Carrier
_
El Disinterment
Date Cemetery Address u —
❑Reinterment
• Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. .__._ 00211
Address
24 Church St., Lake Luzerne,NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
ta. Address
!
Permission is h reb granted to dispose of the human mains escribe above a Indic-ted.
Date Issued(') j fD C L3 Registrar of Vital Statistics _ '
(si ature
,
?, District Number i�Q/ Place A
I certify that the remains of the decedent identified above were disposed of in accordance with this ,,ermit on:
i- f
DILIate of Disposition �'�l'1 Place of Disposition -QLA w Co- 4+✓,-
2 (address)
i1J
(I)
CC (section) - (lot number (grave number)
Name of Sexton or Person in Charge of Premises r, ) 3CI nt/f
2 (please print)
I l Signature Ly._. Title Cis }k7i017
DOH-1555 (10/89) p. 1 of 2 VS-61