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Brooking, Gary Francis _4 , Its -no NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gary Francis Brooking Male Date of Death Age If Veteran of U.S.Armed Forces, 03/14/2021 69 Years War or Dates F. Place of Death Hospital,Institution or WCity,Town or Village Fort Ann Village Street Address 25 Canal Street,Fort Ann Village,New York 12827 p Manner of Death © Natural Cause 0 Accident 0 Homicide ❑Suicide ID Undetermined 0 Pending Ili V Circumstances Investigation W Medical Certifier Name Title Nicholas Montello NP Address 1019 Wicker St,Ticonderoga Town,New York 12883 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann Village 5723 1 0 Burial Date Cemetery,Crematory or Facility Name 03/15/2021 Pineview Crematorium ❑Entombment Address 0 Cremation Queensbury Town,New York ❑Donation ,Z`❑ Removal Date Place Removed and/or and/or Held 0 Hold Address 1'/ Transportation Date Point of ES by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom `E.. Remains are Shipped,If Other than Above a Address C ttt Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/15/2021 Registrar of Vital Statistics Barbara J Winchel►(Electronically Signed) (signature) District Number 5723 Place Fort Ann Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 31 J S 171 Place of Disposition .,,,.,�L �G,_ W (address) IlU (section) (lot number) (grave number) Name of Sexton or Person in Charge of Pre ises Cit f:' \-. LvNAAtl (please print) W Signature L°� Title 4 hay imIT(uIf DOH-1555(07/18)p 1 of 2 1 At- Ir Public Health Law Sec. 4145(2b) 0,14638 Receipt Human remains of delivered on , 20_�' I' Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# f