Fallon, Brenda ` NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
, Name First Middle Last Sex
Brenda Kay Fallon Female
ccei Date of Death Age If Veteran of U.S. Armed Forces,
05/25/2018 49 Years War or Dates
Si.' Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death El NaturalCause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending
Circumstances Investigation
W Medical Certifier Name Title
O Suzanne Rayeski DO
Address
111, 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 258
❑Burial Date Cemetery or Crematory
05/29/2018 Pine View Crematorium
❑Entombment Address
' ; ®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
N Hold
Q Date Point of
Di 0 Transportation Shipment
G by Common Destination
Carrier
1-1
Disinterment Date Cemetery Address
❑Reinterment� Date Cemetery Address
, Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
! Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped, If Other than Above
2 Address
CC
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/29/2018 Registrar of Vital Statistics xo5ertA Curtis tEactrannkat Signed)
(signature)
F District Number 5601 Place Glens Falls, New York
F- I certify that the remains of the decedent identified above were disposed of in accordancet with this permit on:
WDate of Disposition c At I I$ Place of Disposition 1:�V--- eiviti,,,
(address)
Cl,
CC (section) (1 number) (grave number)
8 Name of Sexton or Person in Charge of Premises ihn+i iL 3.--00
Z (pleas print)
W. A
Signature 41 Title /'F-ii+liTc L
(over)
DOH-1555 (02/2004)