Brownell, Baby B NEW YORK STATE DEPARTMENT OF HEALTH , 1 # 11,C
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Baby B Brownell Male
Date of Death Ages �1 If Veteran of U.S. Armed Forces,
June 12, 2018 FeAaQ War or Dates
Place of Death /} �� Hospital, Institution or
City, Town or Village (� Street Address Samaritan Hospital
Ci ®Manner of Death Natu al Cause Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
a Circumstances Investigation
W Medical Certifier Name Title
G- Ellen M. Biggers, Dr.
Addres •
s
SGrnar, 1 t�5 p . -rP -Troi , Jul
,, Death Certificate Filed n / District Number � Z Register Number
` : ,
City, Town or Village ( / Of m i. ./0 777
0 Burial Date Cem tery or Crematory
lo 1 )`l 12 01? I),n J,e,4...� Crean-.o'bri
❑Entombment Address .r
®Cremation b tk e_e_ti �a(- J1
Date (l I Plac Removed
El Removal and/or Held
and/or Address �'
_' Hold
0 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
E Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
n Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
ti Remains are Shipped, If Other than Above
' Address
te
- Permission is h reby granted to dispose of the human re s d scrib abo as indicated.
Date Issued ZQ 1- Registrar of Vital Statistics i�� -o
(signature)
District Number q j 6 2 Place / G ' 71/R-tf
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition b/i f�i Place of Disposition (�.✓ /rM-(dry
(address)
te (section) "pot number) (grave number)
Name of Sexton or Person in Charge o Premises `ir,) 4'' -i,^itr
(plelase print)
IIIS•
ignature Title ifairorriet
1
(over)
DOH-1555 (02/2004)
_