Brownell, Robert .� NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
Name First Middle Last Sex
ROBERT J. BROWNELL MALE
'. Date of Death Age If Veteran of U.S. Armed Forces,
06/01/1997 66 years War or Dates KOREAN WAR
Place of Death Hospital, Institution or
City, Town or Village GLENS FALLS Street Address GLENS FALLS HOSPITAL
Manner of Death Natural Cause Accident Homicide ❑Suicide ElUndetermined Pending
Circumstances Investigation
Medical Certifier Name Title
DAVID SCHWENKER M. D.
Address
90 SOUTH STREET GLENS FALLS NY 1E801
Death Certificate Filed District Number Register Number
'< City, Town or Village GLENS FALLS 5601 252
Date Cemetery or Crematory
El Burial 02/1997 RINEVIEW CREMATORY
Address
Cremation QUEENSBURY NY 1 804
Date Place Removed
8❑Removal and/or Held
*— and/or Address
Hold
Q Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MASON FUNERAL HOME 01221
<' Address
63 GEORGE ST. FORT ANN NY 12827
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 abo e aqffldicated.
Date Issued,,, ,,,, ,,9W Registrar of Vital Statistics `
(signature)
District Numbers Place-- cos c
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition +" Place of Disposition / r`y �% / e /Ye JO1-
Ss, (address)
iU
t/J
>� (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises m l C.o art L L.oloe-
0 , (please print) _
Signature Title `2'
DOH-1555 (10/89) p. 1 of 2 VS-61