St. John, Brandon Thomas .; ULF Ji- bK,-,
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Brandon Thomas St.John Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/14/2022 27 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Kingsbury Town Street Address 130 Broad Street,Kingsbury Town,New York 12839
p Manner of Death ❑Natural Cause Accident ❑Homicide ri Suicide riUndetermined a Pending
IllCircumstances Investigation
WMedical Certifier Name Title
p Wesley Perry Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Town Of Kingsbury District Number Register Number
City,Town or Village 5762 11
Burial Date Cemetery,Crematory or Facility Name
05/25/2022 Pine View Crematorium
Entombment Address
nCremation Queensbury Town,New York
Donation
g n Removal Date Place Removed
and/or and/or Held
H Hold Address
(0
0
0.. Date Point of
Cl)❑Transportation Shipment
p by Common
Carrier Destination
o
Disinterment
Date Cemetery Address
n Date Cemetery Address
I Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
Address
CC
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/19/2022 Registrar of Vital Statistics Cynthia cBardin(EfectronicaCCy Signed)
(signature)
District Number 5762 Place Town Of Kingsbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ + /51—"'"
Z Date of Disposition Ill� I it Place of Disposition �ktv�•--
w g (address)
w
CCCC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises T se >nM�
g
(P print) yM
w Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#