Middlebrook, Wayne F P1SZ
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Wayne F Middlebrook Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/14/2022 82 Years War or Dates 1957-63
Place of Death Hospital,Institution or
WCity,Town or Village Greenfield Town Street Address 331 Porter Corners Road,Greenfield Town,New York 12859
p Manner of Death Natural Cause El Accident El Homicide El Suicide Undetermined 11 Pending
W Circumstances Investigation
W Medical Certifier Name Title
Susan Muller MD
Address
510 Geyser Road,Ballston Spa Village,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Greenfield Center 4557 9
▪Burial Date Cemetery,Crematory or Facility Name
02/16/2022 Pineview Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
▪Donation
Removal Date Place Removed
and/or and/or Held
H N Hold Address
0
Q. Date Point of
Cl) 11 Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/15/2022 Registrar of Vital Statistics Louise Okoniewski(Electronically Signed)
(signature)
District Number 4557 Place Greenfield Center, 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 Z f i1 1ZZ Place of Disposition «J Art4
(address)
W
NCC (section) Cumber)( f /grave number/
Name of Sexton or Person in Charge ises `�"�b l
(please print)
z C
W Signature Title
DOH-1555(07/18)p 1 of 2
♦_ a
Public Health Law Sec. 4145(2b) 1 5 6 5 2
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#