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Breen, John T. 1 zog NEW YORKSTATE DEPARTMENT OF HEALTH r Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John T.Breen Male Date of Death Age If Veteran of U.S.Armed Forces, 11/13/2020 82 Years War or Dates t— Place of Death Hospital,Institution or WCity,Town or Village Lake Luzerne Town Street Address 86 Northwoods Road, Lake Luzerne Town, New York 12804 p Manner of Death ©Natural Cause ❑Accident EI Homicide ❑Suicide Undetermined ❑Pending VCircumstances Investigation WW Medical Certifier Name Title CI William Borgos MD Address 9 Carey Road,Queensbury Town, New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Lake Luzerne 5656 19 ❑Burial Date Cemetery,Crematory or Facility Name 11/16/2020 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation 0 ❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 Q. Date Point of U) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address EjReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom F. Remains are Shipped,If Other than Above 5 Address CC W L' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/16/2020 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed) (signature) District Number 5656 Place Lake Luzerne, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: l Z Date of Disposition illIL)7A Place of Disposition �� j� r,`. W (address) W U) Le (section) (lot number/ (� (grave number) GName of Sexton or Person in Charge of P mises J Ovmn it Z , (........ (p!e se print W Signature o Title ( ie'0 DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014200 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#