Brown, Zachery Uk9 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Zachery Thomas Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 31, 2017 16 War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village ,fir,.-e 6..,4 Street Address Bluebird Road
O Manner of Death❑ Natural Cause n Accident ❑ Homicide ❑ Suicide 1-1 Undetermined ❑ Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
0 Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Deat rtificate Filed District Number Register Number
City, w or Village ,f Ojeet•LA y SRO 2. q
❑Buna Date Cemetery or Crematory
September 7, 2017 Pine View Crematorium
❑ Entombment Address
X❑Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
F. Hold
0 Date Point of
0. ❑ Transportation Shipment
CO by Common Destination
1-3 Carrier
Date Cemetery Address
Ell Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
lX
W Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9/s//7 Registrar of Vital Statistics Al 'i
(signature)
District Number y5(02, Place 77b tips 0- t /34C1C AA_
I certify that the remains of the decedent identified above were di Qsed of in accordance with this permit on:
W Date of Disposition 09/07/2017 Place of Disposition Quaker oad Queensbury, 12804
2 (address)
W
Ct1
W (section) (lot number) (grave number)
0 Name of Sexton or ' C arge of Premises .--, ;,y;/(41,1 [ �.44'1 -6i'c
Z (please print)
W Signature Title 4./2m 4-' ''-
(over)
DOH-1555 (02/2004)