Brown, Shirley E. Ucv�t v tcee�2s ��'c,.
rmE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD. QU 18)79��Y. NEW YORK 12801
i
(5 I8) 79;3-9777
Funeral Dirictor
®1441/VI Case No. "aa.0
IIvnP. S,
Date of Cremation
,I,inM Cremation Started �
'Time Cremation completed D i�
of CcmtainerPciforks
s �A 1
-- -�-- — H Al ,
O � �
F. 1
OCT 06 '0 04:46
*o7-o70
Att. : Walker Brothers Co.
Funeral Home, Inc.
TOWN OF RUEENSHURY
PINK VIEW CENWMRY
CREMATORIUM Q ►_
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTHORIZATION TO CREMATE
'I'he undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains oft
Br Female
Name sex
1669 Reed Road Bergen New York 14416
Street ty State Zip Code
who died on 6 th day of October 19 90
at Glens Falls Hospital Glens Falls, New York
Place ddress
Name and address of nearest living relative or name of person authorizing cremation:
James E. Brown 1669 Reed Road, Bergen, New York 14416
N a—MeT TXUress)
Relationship to the deceased Husband
Name of the funeral home Walker Brothers Co. Funeral Home Inc.
21 South Main Street, Churchville, New York 14428
IMPORTANT:
1 represent that to the best of my knowledge, the deceased has or has no pacemaker in his
or her body. (CIRCLE ONE)
1 certify that I have the full power art� a....,4,i'=4atlon to arrange for the cremation of the
remains and to direct the disposition of the cremated remains, that any personal possessions
have either been removed or may be destroyed, and agree to protect, defend and save harmless
Pine View Crematorium, from any and all -le-ims and demands for loss or damages which
may be made against them by reason of, or ..nnected with the cremation of saifi re,..,et.._
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Shirley...........:.:...............................E.�..:......... Brown.. fe.ma.ae:....::...
9
Date of Death Age
If Veteran of U.S.Armed Forces,
October.:.6..:....1990 62_:: .....War or Dates..: ..: :.:no...:::.............. :...:.::.
H ................:...
Z Place of Death Hospital, Institution or
�{ City,Town or Village City of Glens Falls Street Address Glens...Fol]s...:Hos.otal
C2 Manner of Death Undetermined Pending
W 0 Natural Cause ❑ Accident Homicide ❑ Suicide g
Circumstances Investigation
.... ... ... ...... ................... ... ........ _.... ......... ......... -
W Medical Certifier Name Title
G William F. Orluk MD
............................:.::: ........ .:::..
Address
Main Street Chestertown New. York 12817
Death Certificate Filed District Number Registteerr Number
City,City,Town or Village City of Glens Falls
Date Cemetery or Crematory
❑Buriala October g 1990 Pine View Crematorium
.:::.. .. ....:: ..... __
[Cremation Address
Queensbury, New York
........................ ........ ..... ..
Z Date Place Removed
0 Removal and/or Held
F- and/or Hold ............................ _ .. .............. ...........-.......................
Address
N
0...................................::..............................................................................
a Date Point of
v>' Transportation by: Shipment
p' Common Carrier ............... .. :. ....:: . ........ . .........
Destination
.::: ..... ...........:::. _ __............................. _.
El Disinterment
Date Cemetery Address
. .:..... .. ...
:: :.:.. . . :............
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Regan_and: De.nn..y Funeral:........ .G.e:,.:: n.G:A.._.:_ _.......01.634.._........................
. ......... ......
Address
....:::...:..:...:2:6..:Rucker..:RQ.ad......Q.ueen:sbur.y, :N.e.w..York...12804....... .::::::.:...........:...:. . :::::::........::::::.::.::::.
i-: Name of Funeral Firm Making Disposition or to Whom
g Remains are Shipped, If Other than Above
............................ . :::..:........ ._ ::.....:.........................: ....: :. :.. ........ ......
� .... ,.
Address
<t31'
IZ>
......
Permission Is hereby granted to dispose of the human remains daspribed above s'vindicated.
Date Issued fi _ Registrar of Vital Statistics
(signature)
District Number Place i o eL� %�f. Zl/o v�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F..', i .0 i
W` Date of Disposition ��— �' Place of Disposition //y, - !//,��c.� � /Y/Fl4
2 (address)
w
Cn (section) (lot number) (grave number)
c
p Name of Sexton o ersVinhar a of Premises
Z: (please print) �' r -�
W Signature ) Title
DOH-1555 (10/89) p. 1 of 2 VS-61