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Brown, Eva .,. i J3 NEW YORK STATE DEPARTMENT OF HEALTH I 1. Vital Records Section Burial - Transit Permit Name First Middle Last Sex Eva 011idine Brown Female Date of Death Age If Veteran of U.S. Armed Forces, January 22, 2016 92 War or Dates 1— Place of Death Hospital, Institution or W City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC. WManner of Death Natural Cause 0 Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending it..) Circumstances Investigation W Medical Certifier Name Title CI Nawed Siddiqui, M.D. Dr. Address 100 Park Street Glens Falls, NY 12801 Death Certificate Filed Districtc Number Register Number City, Town or Village SJ ❑Burial Date Cemetery or Crematory January 25, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address Hold 0) Date Point of ilk. ❑Transportation Shipment 0) by Common Destination Ci Carrier [II 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 I— Remains are Shipped, If Other than Above 2 Address It W " Permission is he by ranted to dispose of the human r= •s dgscribed a• • e as i icated. Date Issued / _ Registrar of Vital Statistic„ , d ,- L.1 i �,� (signature) District Numbers �y,Place i ��5�� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 01/25/2016 Place of Disposition Quaker Road Queensbury,NY 12804 (address) WCO IX (section) (lot number) (grave number) Q 0 Name of Sexton or Person in Charge Premises g 3 S1,4�a� lease print) W Signature l� Title C4ik (over) DOH-1555 (02/2004)