Brown, Rena NEW YORK STATE DEPARTMENT OF HEALTH tr 6ZC)
Vital Records Section • 1 Burial - Transit Permit
a Name First Middle Last Sex
Rena Ethel Brown Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 14, 2011 54 War or Dates
Place of Death Hospital, Institution or
W' City, Town or Village Queensbury Street Address
el Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
MI
Medical Certifier Name Title
Aqeel A. Gillani, M.D.',
Address
102 Park Street, Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 J`,33
❑Burial Date Cemetery or Crematory
December 19, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
` Date Place Removed
z ❑ Removal and/or Held
and/or Address
p Hold
O Date Point of
e ❑Transportation Shipment
GI by Common Destination
O Carrier
[' Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
i Address
W'
Permission is hereby granted to dispose of the human rems cZZI ab ve Citilicated.
Date Issued /. _/5--.a t, Registrar of Vital Statistics ) j
(signature)
District Number 4,106--? Place „_,C-- �.� -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ju Date of Disposition to loll Place of Disposition gg,op,.., Cirn..ctd'riw .
z`' (address)
Ul
iir (section) .._ (lot numb (grave number)
0 Name of Sexton or Person in Char a of Premises �irist •
Z ---Aft (please print)
:' SignatureTitle CQ,O Mtt ,
(over)
DOH-1555 (02/2004)