Brownell, Joan NEW YORK STATE DEPARTMENT OF HEALTH A11
Vital Records Section t - Burial - Transit Permit
Name First Middle • Last Sex
Joan Marie Brownell Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 20, 2013 74 War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village South Glens Falls Street Address 20 Riverview Dr, Midtown Apt. 108B
W; Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
tii Medical Certifier Name Title
-- Amy Hogan-Moulton, M.D. Dr.
Address
2 Broad St. Plaza Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
September 25, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold
CO Date Point of
e ❑Transportation Shipment
CO by Common Destination
i Carrier
=; ❑ Disinterment Date Cemetery Address
Date Cemetery Address
El 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
Address
Ct
Ili;
0. Permission is hereby granted to dispose of the human remains s ibed above mdic d. C
Date Issued r/a�113 Registrar of Vital Statistics
(sig ature)
District Number V 445.aLl Place 3Ok 6 ) S ,-. 1.315
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r!
w Date of Disposition 1IVol13 Place of Disposition L Ps60
(address)
Ui
co
ft (section) (lot nu ber) (grave number)
r'
`1h ` -C1r''�ti
CI Name of Sexton or Person in C F.rge of Prem' es
(please print
W Signature I Title CatnoTo1
(over)
DOH-1555 (02/2004)