Brown, Jeffrey OF QUEE BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director
Fame-- �t'� rpm sr�:.'Vj
Case
Date Of Cremation
T1me Cremation Started
T ! me Cremation Completed 10 ' 36
'ype of Container
Remarks
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeffrey grown
--
Date of Death Te If Veteran of U.S. Armed Forces,
12/30/200650 War or Dates no
IH Place of Death 'own of Fort Edward Hospital, Institution orFortoHudsonaNuurs n 12328
er
Z City, Town or Village Street Address
wo
0 Manner of Death®Natural Cause F]Accident [-]Homicide Suicide Ej Undetermined Ej Pending
W Circumstances Investigation
Medical Certifier Name Title
� Dr. Allison Harbour MT)
Address
Fort ^dward, NY 12828
Fort
Death Certificate Filed is ct um Register Number
City, Town or Village
El
Burial Date Cemetery or rematory
,Ian. 03, 2007 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road �uK ens bur NY 12,904
Date Place Removed
❑Removal and/or Held
.. and/or Address
F=` Hold
fl#
0 Date Point of
Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M• R. Kilmer Funeral Home 01141
Address
136 Main 5t. South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
141 Remains are Shipped, If Other than Above
Address
` Permission is qerepy granted to dispose of the human r ins described ab ve7asdicated.
Date Issued` Registrar of Vital Statistic1,4
17 J— (signature)
District Number 7 Place6D Z�j
I certify that the remains of the decedent identified abovee6ple disposed of in accordance with this permit on:
W Date of Disposition Place of Disposition i n r 2 V r.,.,,nI r
(address)
ilt
(section) (lot number) (grave number)
Name of Sexton Person in Charge of Premises rint
(please P )
Signature ` Title +'�+n
(over)
DOH-1555 (02/2004)