Brown, Carolyn Anne NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Carolyn Anne Brown 7 Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/26/2020 85 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death ❑X Natural Cause Accident Homicide 1:1Suicide Undetermined Pending
VCircumstances Investigation
G Medical Certifier Name Title
John Quaresima MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town orVillage Fort Edward 5755 35
Burial Date Cemetery,Crematory or Facility Name
04/27/2020 Pine View Crematory
Entombment Address
X Cremation Queensbury Town,New York
Donation
0 ❑Removal Date Place Removed
H and/or and/or Held
N Hold Address
O
IL Date Point of
to ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
2 Address
Q
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/27/2020 Registrar of Vital Statistics f3imee5bw oney(E&--'ro---1T Sy-d)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of
the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition /-ZQ-Zp Z!� Place of Disposition ��)�1 4-9j C!e ✓+'7 r
Uj (address)
W
N
� (section) � (lot number) (grave number)
0 Name of Sexton or Perso C rge f Premises G✓�
Z (please print)
W Signature Title
DOH-1555(o7/18)p 1 Of 2
Public Health Law Sec. 4145(2b) 0—1, 6 2
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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