Brown, Katherine A. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
1y.
Name First Middle Last l Sex
Katherine L Brown j Female
Date of Death Age I If Veteran of U.S. Armed Forces,
must 2, 2011 90 1 War or Dates
E,. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
US Circumstances Investigation
us, Medical Certifier Name Title
q Susanne Blood,MD
Address
14 Manor Dr.,Queensbury,NY 12804
Death Certificate Filed District Numbe5601 Regie r 1N tuber
City, Town or Village Glens Falls ! L..--
❑X Burial Date Cemetery or Crematory
August 5, 2011 Pine View Cemetery
❑Entombment Address
LJ Cremation � Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal j and/or Held
2 and/or Address
H Hold '.
O Date Point of
a.
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 1 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
5, Address
U —
.Q Permission is herebAnted to dispose of the human remains descri ed above indi e .
Date Issued 0 // Registrar of Vital Statistics `
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 8/5/11 Place of Disposition Pine View Cemetery
2 (address)
to Mohican 72D 6
CL (section) (lot number) (grave number)
QName of Sexton or Person i Charge of Premises Michael Genier
Z (please print)
us
Signature ( 'NJ Title Superintendent
(over)
DOH-1555(02/2004)