Been, Timothy E NEW YORK STATE DEPARTMENT OF HEALTH 4 55y
Bureau of Vital Records J •
Burial - Transit Permit
Name First Middle ,
Timothy E.Been Last Sex
Date of Death Male
Age If Veteran of U.S.Armed Forces,
07/12/2022 58 Years War or Dates
1... Place of Death
Hospital,Institution or
W City,Town or Village Milton Town Street Address 566 Rowland Street Ext., Milton Town, New York 12866
0 Manner of Death Ej Natural Cause Accident W Homicide Suicide ❑Undetermined ❑Pending
U Circumstances Investigation
Q Medical Certifier Name
Title
Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Milton District Number
City,Town or Village Register Number
4561 30
Burial Entombment Date I Cemetery,Crematory or Facility Name
07/13/2022 Pine View Crematory
Address
Cremation Queensbury Town, New York
ElDonation
..Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
(n❑Transportation
Efl by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to
Name of Funeral Home Brewer Funeral Home Inc Registration Number
Address 00211
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
2 Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/13/2022 Registrar of Vital Statistics Brenda Howe(Electronically Signed)
(signature)
District Number 4561 Place Town Of Milton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition lily lit Place of Disposition
-f� .V� 4 -._._.
(address)
W
N
tt
(section) 4 (lot number) (grave number)
Name of Sexton or Person in Charge of P e ises <<t L oh-cat
Z (ple4e print/
W Signature
L�—k' Title -- Di
g
DOH-1555(07/18)p 1 of 2
• t 7,r,
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#