Brierton, Gary 11 6oy
NEW YORK STATE DEPARTMENT OF HEALTH s 'Vital Records Section Burial _ Transit Permit
Name First Middle Last Sex
Gary Brierton Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 12, 2013 78 War or Dates Vietnam
1... Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address 14 Hoyt Ave
pManner of Death Natural Cause Accident n I I Homicide Suicide Undetermined �Pending
Circumstances Investigation
G Medical Certifier Name Title William Tedesco PIP
tP
Address
3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
❑Entombment October 15, 2013 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
O and/or Address
E Hold
CO
aDate Point of
(151-1 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
w
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I n J i 5 /t 3-- Registrar of Vital Statistics (_,j t.,0
(signat )
AT
District Number 5601 Place Glens Falls / y /,2 7/
I certify that the remains of the decedent identified above were disposed of (iinaccordance with this permit on:
P Cisciou--
� Date of Disposition 10t l c it) Place of Disposition
W (address)
CO
tr
(section) (lot nur) (grave number)
p Name of Sexton or Perso in Charge of Premises AILw./�.
W (please print)
Signature Title OLG(N(}t
(over)
DOH-1555(02/2004)