Brown, Vera NEW YORK STATE DEPARTMENT OF HEALTH v `9%4
Vital Records Section Burial - Transit Permit
II
Name First Middle Last Sex
Vera L. Brown Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 5,2011 93 War or Dates World War II
1 Place of Death Hospital, Institution or
City, Town or Village Warrensburg Street Address 431 Schroon River Road
Manner of Death "Undetermined Pending
X Natural Cause Accident Homicide Suicide
iti Circumstances Investigation
O.
lit Medical Certifier Name Title
:0_, Diane MacDonnell Dr.
Address
461 Glen Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
r' City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
CEntombment October 6,2011 Pine View Crematory
Address
El Cremation Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal 1 and/or Held
O 1 land/or Address
H Hold
0
00 Date Point of
N Transportation Shipment
p by Common Destination
Carrier
I I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
E►1 Remains are Shipped, If Other than Above
Address
a
Permission is h/ereb g nted to dispose of the human - - cribed a4, .ve as indicated.
Date Issued `O � / Registrar of Vital Statist. Lii ,/I r I,L
(signature)
District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Ill Date of Disposition 10•-)- /1 Place of Disposition :rR Jc c34,,,, Cre yi— 4ol c u;-N
W (address)
Ca
0 (section (lot n tuber) (grave number)
p Name of Sexton or Person in Charge of Premises l i vvia-i--h I ru vie Ye_
W (please riot)
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14,Signature ,�J�� J _ Title CI-ern CAvr7 1 S4-
(over)
DOH-1555 (02/2004)