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Brown, Allen NEW YORK STATE DEPARTMENT OF HEALTH r 't �Gi, Vital Records Section Burial - Transit a it Name First Middle Last Sex Allen "Joe" Brown Male Date of Death Age If Veteran of U.S. Armed Forces, June 11, 2017 53 War or Dates Z Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address 229 Broadway WManner of Death ® Natural Cause n Accident E Homicide 0 Suicide Undetermined 1pi l Pending Circumstances Investigation WW Medical Certifier Name Title Michael Fuller, Dr. Address 100 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number��"��, Register Nu r City, Town or Village Fort Edward ❑ Burial Date Cemetery or Crematory June 13, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z I-1 Removal and/or Held • f I and/or Address p. Hold U ' Date Point of eL Transportation Shipment 0) by Common Destination CI Carrier Date Cemetery Address n Disinterment Date Cemetery Address n Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom 1—' Remains are Shipped, If Other than Above • Address CK d' Permission is hereby granted to dispose of the humarnr ains describ d b ye des indicated. Issued�p-13 0 E-, 01-1 Registrar of Vital Statistics - �(_ � 7Jc wLU (signature) G District Number 57 55 Place ) y iJYi` 6 . l(.vai cl I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z; Date of Disposition 06/13/2017 W p Place of Disposition Quaker Road Queensbury,NY 12804 2' (address) W CO (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Pre ises tiiifl f _SL„1`t if- W (pl ase print) T Signature �i j Title ( tkiik, (over) DOH-1555 (02/2004)