Brown, Lester NEW YORK STATE DEPARTMENT OF HEALTH + II, It 79
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
Lester Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 22, 2013 86 War or Dates
1 Place of Death Hospital, Institution or
u City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
€]° Manner of Death Natural Cause El Accident ❑ Homicide ❑ Suicide El Undetermined ❑ Pending
UJ Circumstances Investigation
t:)
W Medical Certifier Name Title
CI Eileen Spinelli, NP
Address
9 Carey Rd Queensbury,NY 12804
Death Certificate Filed District Number Registe t tuber
City, Town or Village .5-7c5--
❑Burial ' Date Cemetery or Crematory
December 2‘ 2013 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
ElRemoval and/or Held
• and/or Address
E Hold Union Cemetery
N Date Point of
a0 Transportation Shipment
CO by Common Destination
O Carrier
Date Cemetery Address
❑ Disinterment
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
F Remains are Shipped, If Other than Above
2 Address
W
p. Permission is hereby granted to dispose of the human re ins described ove indicated.
Date Issued%Q -j(� -/3 Registrar of Vital Statistic
(signature
District Number)-7 55 Place ,, j �_.
F. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11- �-t3 Place of Disposition ?A (,�r•ci a" crA,
2 (address)
W
Ce (section) (lot umber) c (grave number)
pName of Sexton or Person in harge of Pr ises i4f ""'
J (please print)
W Signature l� Title at ino Ril
(over)
DOH-1555 (02/2004)