Brock, Bernard W LOF
NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records 4 Burial - Transit Permit
Name First Middle Last Sex
Bernard W.Brock Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/23/2022 83 Years War or Dates
�., Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
WW Manner of Death
Natural Cause Accident Homicide Suicide Undetermined ❑Pending
V Circumstances Investigation
G Medical Certifier Name Title
Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 386
Burial Date Cemetery,Crematory or Facility Name
07/26/2022 Pine View Crematory
Entombment Address
aCremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
H and/or and/or Held
N Hold Address
0
O. Date Point of
U)OTransportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
2 Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/25/2022 Registrar of Vital Statistics Megan Nolin(ECectronicaQy 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:
� Lr
W Date of Disposition 7 T7��03 y Place of Disposition e V I G� V` ,n c-l0 f y
(address)
W
N (section) (lot number) (grave number)
8 Name of Sexton or Pe on in Charge of Premises sTed.df,.i C.Y SiGjJ e,S
ease print)
W Signature Title Gceyn �
DOH-155 7/18)p 1 of 2
T ci6
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pixie VieW Cemetery Repres&ttting the funeral home named on buriatl permit
Official Funeral Directors Reg.or License# -