Brooking, James M NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
James M Brooking Male
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Date of Death Age If Veteran of U.S.Armed Forces,
November4, 1990........................7�..:..:...... War or Dates.................:.................... .:... .:............:......:................................... . . .......:.:.......:..............._:::::...::::.
Z, Place of Death Hospital, Institution or
City,Town or c_: Village Stillwater Street Address 156 Lohnes Rd.
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aus..e of Death
Cardiac Astystole
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Medical Certifier Name Title
p' Paul J. O'Kosky MD
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Address
80 Seward St. , Saratoga Springs, N.Y. 12866
Death Certificate Filed Distr............................
ct Number Register Number.............:.:........
City,Town or Village Stillwater 4567 10
Date Cemetery or Crematory
❑Burial November 6, 1990 Pine View Crematory
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®Cremation ,
Address ....:..::.
Queensbury, N.Y.
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Z; Date Place Removed
O, ❑ Removal and/or Held
F-; and/or Hold:.....-......................... _ ......... .....:::-....................::.................................................:..::..............._.
Address ...:.:.........................................................
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U., Date Point of
❑Transportation by Shipment
fll Common Carrier ........................................................
_.....
Destination
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❑ Disinterment Date Cemetery Address
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❑ Reinterment Date Cemetery Address
<: Permit Issued to Registration Number
.::..
Name of Funeral Firm Flynn Bros. ,, Inc. 00680
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Address _...:........:.......................:................:
13 Gates Ave. , Schuylerville, N.Y. 12871
c..:.Name of Funeral Firm Making D.is.Disposition or to Whoni::::::.......................................................................................................................................................
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Remains are Shipped, If Other than Above
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Address
Permission Is hereby granted to dispose of the dead human remains described above as indicated.
Date Issued 11/5/90 Registrar of Vital Statistics
(signature)
District Number 4567 place Town of Stillwater
certify that the remains of the decedent identified above were disposed of in accordance with this permit on: J
w'. Date of Disposition 'd 0 Place of Disposition �/—//w le- /0
g!, (address)
>w;
(section) pp �j� p (lot number) (grave number)
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a Name of Secton r Person in har a of Premises
2
W Signature (please print) Title
DOH -1555 (9/86)p 1 of 2(formerly VS-61)