Linedoll, Brian John LF St 7'70
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital.Records
Name First Middle Last Sex
Brian John Linendoll Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/24/2022 59 Years War or Dates
!H Place of Death Hospital,Institution or
2 City,Town or Village Glens Falls Street Address Glens Falls Hospital
ILI
a Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined ❑Pending
111
0Circumstances Investigation
W.O Medical Certifier Name Title
Mathew Varughese JO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Nur Register Number
ty,Town orVillage 5601 _ 180 _
Burial Date Cemetery,Crematory or Facility ie
® 03/28/2022 Pine View Crematory
Entombment Address
[Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
i- Hold Address
co
n
# Date Point of
Transportation
by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
tC
al
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/28/2022 Registrar of Vital Statistics Megan Nolin(E1 ctmnica(ly Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 317Siq Place of Disposition l '"L �� (h.. r 4_
US
2 (addres3/
U
Q (section) (il
(lot number) (grave number)
8 Name of Sexton or Person in Charge of Premises �'s 'Pl -- N11 41If
Z ` (p se print) �yy
Signature s`.�� Title 1���1 n 1 V(
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) ` U
Receipt
Human remains of delivered on , 20
w Cemetery Representing the funeral home named on burial permit
Funeral Directors Reg.or License#