Brown, Dorothea NEW YORK STATE DEPARTMENT OF HEALTH # q'/
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dorothea iE Brown Female
Date of Death Age If Veteran of U.S. Armed Forces,
06 / 04 / 2016 86 War or Dates N/A
1-- Place of Death Hospital, Institution or
ZCity, Town or Village Granville Street Address Haynes House of Hope
a Manner of Death®Natural Cause 0 Accident Homicide E Suicide 0 Undetermined 0 Pending
IliCircumstances Investigation
tu Medical Certifier Name Title
0 David M. Mastrianni MD
Address
3 Care Ln Ste 300 Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Granville 5r15(Q a(a
iilo CI Burial Date Cemetery or Crematory
06 / 06 / 2016 Pine View Crematory
0Entombmentmi< >: Address
lCremation 21 Quaker Road, Queensbury, NY 12804
`'" Date Place Removed
1❑Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
iM
❑Reinterment Date i Cemetery Address
Oii Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
Address
402 Maple Ave., Saratoga Springs, NY 12866
iia
iNi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
cr
f
'` Permission is hereby granted to dispose of the human remains described above as indicated.
liii!i!i Date Issued Le`Cp ,3L t Registrar of Vital Statistics .G is`.
,t (signature)
District Number 69,LF Place anville , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
w Date of Disposition ( 'gm, Place of Disposition fuili.A.—.1 ilrr,q -nrtt--
ME (address)
iti
CICC (section) (lot number) -w�, (grave number)
Name of Sexton or Person ip Charge of Premises - tN c - r_ .i 'l/
a (,� ease print
Signature Title -gi1'f f
g.
(over)
DOH-1555 (02/2004)