Brown, Mary ! # 31
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle - Last Sex
Mary Dawn Brown Female
Date of Death Age If Veteran of U.S.Armed Forces,
M 23,2016 • 92 War or Dates
M. July
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 95 Country Club Road
Manner of Death 1 ❑Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Gerald F Abess
Address
ti 3 Irongate Center
Dea i cate File District Number Re ister Number
_ Ci ,Town or illage��,�,�?)-�/ -j �� yA
❑Bun Date Cemetery or Crematory
July 25, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804 -
Date Place Removed
ZZ ri Removal and/or Held
and/or Address
E Hold
CO
0 Date 1 Point of
N0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
1 Permit Issued to Registration Number
•;' Name of Funeral Home Regan Denny Stafford Funeral Home 01443
f% Address
���fi
r.. ,
53 Quaker Road,Queensbury,NY 12804
P Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re�pains described a re as indicated.
I
f;<; Date Issued -1 ijc dbl c-) Registrar of Vital Statistics CA--,:_
,;A: (signature)
M District Number G(o'r) Place / d (, 0 '1^ Ca_L by
I certify that the remains of the decedent identified above were disposed of in accordannwith this permit on:
F-
Z /, ��
W Date of Disposition 7/ Z61'b Place of Disposition eN i ` ri"64 014%--
2 (address)
W
Cl)
Ct (section) /j (lot number) r (grave number)
pName of Sexton or Person in Charge of Premises G4r�s i` tw.'''
Z ( lease print)
W Signature (14 6 Title �l {71(
' (over)
DOH-1555(02/2004)