Heller, Bryan H NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Bryan H Heller Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/03/2022 52 Years War or Dates
F Place of Death Hospital,Institution or
WCity,Town or Village Corinth Town Street Address 24 Stark Place,Corinth Town,New York 12866
p Manner of Death 0 Natural Cause Accident []Homicide Suicide FlUndetermined rid Pending
W
C.) Circumstances Investigation
W Medical Certifier Name Title
0 Robert Ball Coroner
Address
6010 County Farm Road,Ballston Spa Village,New York 12020
Death Certificate Filed Town Of Corinth District Number Register Number
City,Town or Village 4553 9
ElBurial Date Cemetery,Crematory or Facility Name
06/06/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
W
0
d Date Point of
U)❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
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
1— Remains are Shipped,If Other than Above
5 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/06/2022 Registrar of Vital Statistics Brenda L Peris(Electronically Signed)
/signature)
District Number 4553 Place Town Of Corinth
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z f
W Date of Disposition �l�,i ZZ Place of Disposition �;,a(�— a
2 (address)
W
CC (section) (lot number) (grave number)
Q4 S Name of Sexton or Person in Ch of Premises �` ��""
z
(pe print) /�.
W Signature Title b r"� 47Vk
DOH-1555(07/18)p l of 2
b
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#