Brownell, Carol , .,, 71f,
NEW YORK STATE DEPARTMENT OF H: H ``
Vital Records Section w " Burial - Transit Permit
Name First iddle ast Sex
Carol Ann Brownell Female
Date of Death Age If Veteran of U.S. Armed Forces,
ai
04- 10/15/2017 68 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 1 Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined ❑Pending
rr
Circumstances Investigation
Medical Certifier Name Title
x Michael Miles MD
Address
g 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 531
❑Burial Date Cemetery or Crematory
10/16/2017 Pine View Crematory
['Entombment Address
®Cremation Queensbury, New York
Date Place Removed
El❑Removal
d/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
❑Disinterment
Date �`�rCemetery Address
I:Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
pne 53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/16/2017 Registrar of Vital Statistics Men ACurtis fE1ectronicaaySigned-
b (signature)
District Number 5601 Place Glens Falls, New York
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fl
Tr Date of Disposition /a III
i in Place of Disposition oFat t yo, (1,rw.G7 ary
(address)
11
Toe
° (section) �of number) (grave number)
Name of Sexton or Person in Charge of Pr mises ( lr,Ja t,.,'. 11'
r- (ple print)/�,c
Signature 6Tr
Title ( -`miq
(over)
DOH-1555 (02/2004)