Austin, Brian 4 cs-tc
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Brian C. Austin Male
Date of Death Age . If Veteran of U.S. Armed Forces,
September 20,2013 72 War or Dates
,, Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death J Natural Cause n Accident n Homicide n Suicide Undetermined n Pending
Circumstances Investigation
w Medical Certifier Name Title
CI John P. Stoutenburg Dr.
Address
Glens Falls Hosp,Glens Falls,NY 12801
Death Certificate Filed District Number Re t r. Number
City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
❑Entombment September 23, 2013 Pine View Crematorium
Address
CI Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
�' Hold
N
0 Date Point of
Nn Transportation Shipment
a by Common Destination
Carrier
E
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker 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 descr ed above s in d.
Date Issued CV/ 3 Registrar of Vital Statistics ,-dal .,•t/ ` .
signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11/3113 Place of Disposition &and &for, +..
2 (address)
W
co
Ore (section) il (lot umber) (grave number)
Name of Sexton or Person ' Charge of Premises aaaa t,� tin
Z (pl se print)
W IL Signature . Title c M({ nt
(over)
DOH-1555(02/2004)