Brown, Jean NE�W-YO1K STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
1 Jean Margaret Brown Female
Date of Death Age If Veteran of U.S.Armed Forces,
- = March 27, 2014 74 War or Dates
Place of Death Hospital, Institution or
i,` City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Deathril
Lai Natural Cause Accident 0 Homicide El Suicide Undetermined El Pending
Utz-
-E Circumstances Investigation
Fite Medical Certifier Name Title
i Gary Scidmore,
Address
1340 State Route 9 Lake George, NY 12845
Death Certificate Filed District Number Register Numb r
City, Town or Village ��(f /ti..17
j J Burial Date Cemetery or Crematory
April 1, 2014 Pine View Cemetery
❑Entombment Address I,
[]Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Removal and/or Held
Li
and/or Address
' Hold
H Pine View Cemetery
O. Date Point of
c'❑Transportation Shipment
= by Common Destination
Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
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
�` Address
of
CL Permission is hereby gran ed to dispose of the huma(remains scribed a -ye,�aZs,indi ated.
= Date Issued C S 1 Registrar of Vital Statistics �p/ % D2i's
1C ( ure)
"I a--
District Number , 7,o / Place
I certify that the remains of the decedent identified above re disposed of in accordant with this permit on:
1--
Date of Disposition 04/01/2014 Place of Disposition Quaker Rd. Queensbury,NY 12804
(address)
LU Mohawk 1 0 2 1
01
ir (section) (lot number) (grave number)
t' Name of Sexton or Person in Charge of Premises Connie L. Goedert
Z (please print)
Ili Signature Title Superintendent
—
(over)
DOH-1555 (02/2004)