Brown, Esther NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last ` Sex
---- Rrnvn Fenn e
Date of Death Age If Veteran of U.S. Armed Forces-----.,
February 13, 1996 90 War or Dates
Place of Death Hospital, Institution or
L4y-,4 ovarror Village Hudson Falls Street Address 24 LaClaire St.
Manner of Death®Natural Cause Accident Homicide n Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Edwin Fernandez MD
Address - - ---- —_- -
90 South St. , Glens Falls, NY 12839
Death Certificate Filed District Number Register Number
CitX$UQIXyICC$lillage Hudson Falls 5726
Date Cemetery or Crematory
El Burial February 14, 1996 Pine View Crematorium
Address
Cremation Tn of Queensbury, NY 12804
F Date Place Removed
Removal and/or Held
- - -
N and/or Address
-- Hold
Q Date Point of
NTransportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton
Address
_ P.O. Box 67, 68 Main St., Hudson Falls N.Y. 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above _
Address _
Permission is hereby granted to dispose of the human rempins described above as indicated.
Date Issued�_t 4_96 Registrar of Vital Statistics
(signatur
District Number 5726 Place Hudson Falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
g Date of Disposition_ _i Place of Disposition it V �1�Z AA Al,
2 (address)
W
(n
(section) lot number) (grave number)
Name of Sexton or Person in Charge of Premises Ariz-t 69, f' K,
Z (please print)
Signature Title p- 5 ;
DOH-1555 (10/89) p. 1 of 2 VS 61