Havens, Brain H NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Brian H.Havens Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/31/2021 59 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
1p Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Lynn Keil PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 476
❑Burial Date Cemetery,Crematory or Facility Name
11/02/2021 Pine View Crematory❑ — —Entombment Address
0 Cremation Queensbury Town,New York
ElDonation
Z ❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
0
a Date Point of
(/1 ❑Transportation Shipment
Q by Common
Carrier Destination
El Disinterment
Date Cemetery Address
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
N Address
CC
U. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/02/2021 Registrar of Vital Statistics Rp6ertf'nt1rew Curtis(E6ectronicallY-Signe9
(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 1113 I VI Place of Disposition MAIL-
2 eJCO�
ddress/
W
N CC (section) (lot number) (grave number)
c,
GName of Sexton or Person in Charge of Pr ises '14.4 tit
Zn (plea print)
W Signature L/� Title �� '~��
DOH-1555(o7/t8)p t of 2
f' 0 5 2 8 6
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#