Brown, Shannon A t *01 L f
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shannon Irene Brown Female
Date of Death Age If\ktt:en of U.S.Armed Forces,
11/20/2018 41 Years War or Dates
I— Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Q Natural Cause Q Accident 12 Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
Kt Medical Certifier Name Title
C Nawed Siddiqui MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 549
❑Burial Date Cemetery or Crematory
11/27/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
tz Hold
43 Date Point of
a.Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
11-- Remains are Shipped, If Other than Above
Zi Address
w
IL' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/21/2018 Registrar of Vital Statistics gp6e7t.1 Curtis(EkctronrcallySigne4)
(signature)
District Number 5601 Place Glens Falls, 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 /1-01.1,I V Place of Disposition p At, V;e,w, c fe,,Mcrtcry
(address)
111
(seciton) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises -Tam e'Y
(please print)
LLI
Signature \ Title C.Te,✓"c+i a r
(over)
DOH-1555(02/2004)