Brown, Shirley E NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Shirley..::...:....... E......... ......::, Brown.... .....:::. .:... ...:.:...... .:::.....female:::.....:,_.
Date of Death Age If Veteran of U.S. Armed Forces,
October 6 1990 ... _ _..:::.... .....::. 62_:. .....,War or Dates..: no...........:
...: ..:.:::: ... .. ........................
Place of Death Hospital, Institution or
W City Town or Village City of Glens Falls Street Address Glens...Fa.1S,.,Ho .ptal....,:
� Manner of Death ............. .... Undetermined Pending.
�. 0 Natural Cause Accident Homicide SuicideE:i
Circumstances Investigation
........................ ...:.:.: . . _..... ........ ... ...... ........... .......
: Medical Certifier Name Title
p! William F. Orluk MD
...... ..............................................................:......
Address
Main Street Chestertown New York _ 12817
.... ...........
Death Certificate Filed District Number Register NumberNNumber
City,Town or Village City of Glens Falls
Date Cemetery or Crematory
❑Burial
October 8r 1990 Pine View Crematorium
...... .....::. ......:: .......... ..... ..... . ..... .....:::. .........
[Cremation Address
Queensbury, New York
. _ : .. .:_ .... ......... ..... ..::: :::: ..:.:...:.:.. .... .... ......... .....
Z Date Place Removed
>0',, ❑ Removal and/or Held
F- and/or Hold ..................... . ........ .......... -
Address
N
0............... .:.:... ...........:........:.... ...:.. .:.
a Date Point of _:. ............................
to []Transportation by:: Shipment
p Common Carrier .............. . .:: ........
Destination
... .....::::..:. . , ...... ...... :.. ....................................................
ry. _ : ... ... ..........:. . ......
❑ Disinterment
Date Cemete Address
. _......... ......:.....
....... __.....
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
..........Re.gan.a.nd...Penn..y_Funera.l..:9erv.i.ee.,::..Inc............::.._, _ : ,::::._:::.::.01634...........__.
........................... . . ......
26...Qu:aker..:R.oa.d..........Queen.sbury:. N.ew...Yor.k....1.2804 ._. ....... .......................................
Name of Funeral Firm Making Disposition or to Whom
`2 Remains are Shipped, If Other than Above
........................................................................................ .::::. . ... ....... .... ......... ....
Address
.... ......... ... ........................... . .. . ..... ......... ......... ................................
Permission is hereby granted to dispose of the human remains de ribed above s-/�indicated.
Date Issued C &D Registrar of Vital Statisticsr
(signature)
District Number ���/ Place Z �
I certify that the remains of the decedent identified above were disposed off in accordance with this permit on:
W Date of Disposition ��— �— Place of Disposition
>gi (address)
W'.
(section) (lot number)
� / (grave number)
0 g ,Et11.1/9�t l� z r f �72r� mot/
p Name of Sexton o erson in har a of Premises
Z ,/�
W' Signature s lease print) Title ��/l /O l� 1
DOH-1555 (10/89) p. 1 of 2 VS-61