Brown, Sandra Lee # 34s
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Sandra Lee Brown Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/11/2021 58 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 93 South Street,Glens Falls,New York 12801
p Manner of Death ❑X Natural Cause ❑Accident Homicide Suicide ❑Undetermined Pending
W U Circumstances Investigation
• Medical Certifier Name Title
0 Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 176
❑Burial Date Cemetery,Crematory or Facility Name
04/13/2021 Pine View Crematory
ElEntombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Z ❑Removal Date Place Removed
O- and/or and/or Held
- Hold Address
N
0
O. Date Point of
U) ❑Transportation Shipment
by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
CC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/13/2021 Registrar of Vital Statistics fit'poem,7ndreu:Curtis(Ekctronica16,5 ned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition Li!)N'T1b Place of Disposition )
�l
2 (address)
W
CC (section) rum(ier) (grave number)
0 Name of Sexton or Person in Charge of Pre ises d r� ✓�1
e print
W Signature Title
DOH-1555{o7/A8)p t of 2
Public Health Law Sec. 4145(2b) 04 + '
Receipt
Human remains of delivered on 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#