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Sorrell, Dwright E. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dwight E.Sorrell Male Date of Death Age If Veteran of U.S.Armed Forces, 04/09/2021 76 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Hadley Town Street Address 54 Third Avenue, Hadley Town, New York 12835 p Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined ❑Pending W C.) Circumstances Investigation Medical Certifier Name Title George Siniapkin MD Address 604 Palmer Avenue,Corinth Town,New York 12822 Death Certificate Filed District Number Register Number City,Town or Village Hadley 4558 9 ❑Burial Date Cemetery,Crematory or Facility Name 04/10/2021 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York ❑Donation g Removal Date Place Removed and/or and/or Held Hold Address N 0 O. Date Point of U) ❑Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment 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 H Remains are Shipped,If Other than Above M Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/09/2021 Registrar of Vital Statistics Pauline G Smead(Electronically Signed) (signature) District Number 4558 Place Hadley, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition ���tl (Z) Place of Disposition t � — 2 (address) W CC CC (section) /)'lot number) (grave number) Name of Sexton or Person in Charge of Prem. / r` vrn� 1` (pleas print) fri W Signature C il.-a-- Title Pf4itt DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 0147 _t� �. Receipt Human remains of / delivered on , 20t - - Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#