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Brown, David Calvin Io NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex David Calvin Brown Male Date of Death Age If Veteran of U.S.Armed Forces, 01/20/2021 52 Years War or Dates F- Place of Death Hospital,Institution or W City,Town or Village Glens Falls : f Street Address 20 May Street,Glens Falls,New York 12801 p Manner of Death ©Natural Cause Accident Homicide Suicide El Undetermined n Pending UCircumstances Investigation p111 Medical Certifier Name Title Timothy Murphy Coroner Address 52 HAVILAND AVE,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 48 ElBurial Date Cemetery,Crematory or Facility Name 01/25/2021 Pine View Crematorium Entombment Address X❑Cremation Queensbury Town,New York 0 Donation 0 Removal Date Place Removed and/or and/or Held H F.) Hold Address 0 Ua) ❑Transportation Date Point of p by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/25/2021 Registrar of Vital Statistics Rp6ert Andrew Curtis(ECectronicalrySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition /20 ZJ Place of Disposition 2 (address) ce N /section/ j (lot number) (grave number) Name of Sexton or Person in Charge of Premises /t<<� � �H^Mt Z ®J� (ple se print) W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 ._ 5 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#