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Brand, John
} NEW YORK STATE DEPARTMENT OF HEALTH �� Vital Records Section Burial - Transi Permit Name First Middle Last Sex { John Alden Brand Male ,, Date of Death Age If Veteran of U.S. Armed Forces, August 21,2013 66 War or Dates Vietnam — Place of Death Hospital, Institution or City, Town or Village GIens Falls,NY Street Address The Pines At Glens Falls Manner of Death 0 Natural Cause E Accident 0 Homicide n Suicide n Undetermined n Pending Circumstances Investigation ' e Medical Certifier Name Title Maureen Hyland,FNP ire Address - :f, '' Glens Falls,NY 12801 tf,; Death Certificate Filed District Number Register Number City, Town or Village�,� tY� 9 Glens Falls,NY 5601 36 0 Burial Date Cemetery or Crematory ❑Entombment August 22,2013 Pine View Crematorium Address ©Cremation Quaker Road, Queensbury,NY 12804 Date Place Removed ZZ ri Removal and/or Held and/or Address P' Hold a 0 Date Point of N El Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address '% Permit Issued to Registration Number : Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 0 Address 1. 407 Bay Road,Queensbury,NY 12804 f t- ., Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address „ : Permission is hereby granted to dispose of the human remains described above as,indicated. tom', r art Date Issued .S f Z 24/ 3 Registrar of Vital Statistics L.A.) Cx.A.4-y- `A/ {> (signature) El`'X. District Number Place 5601 Glens Falls,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iuDate of Disposition • 1 Place of Disposition at-'L vv."..., 0„..4.147,744714( W (address) V3 It 0 (section) (lot',limber) (grave number) p Name of Sexton or rso in of Premises i �77 w/ Z ( ease print) W Signature L Title 131 (over) DOH-1555(02/2004)