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Brown, Jacqueline Ann Town of Queensbury 411111 Certification of Cremation WPine View Cemetery and Crematory This certifies that the remains of: Jacqueline Ann Brown were cremated on May , 5 20 22 at the Pine View (Month) (Day) Crematorium, Queensbury, New York, and these are the cremated remains of said body. Date of Death May , 2 20 22 Age 68 (Month) (Day) Funeral Home Regan,De ny,Stafford Funeral Home Registered No. 376 n'--1// (Authorized Signature) BROWN NAME Jacqueline Ann Brown Age: 68 Lot Owner: Donald Brown Lot# Algonquin Sec F #85 R8 Grave# 1 Case: Urn Died: 5.2 .2 2 Interred: 5. 1 4.2 2 Funeral Home: Regan Denny Stafford Cemetery: Pine View r ` `/ l V NEW YORK STATE DEPARTMENT OF H EALTH cl,:f Burial - Transit Permit Bureau of Vital Records Name First Middle last Sex Jacqueline Ann Brown Female Date of Death Age If Veteran of U.S.Armed Forces, 05/02/2022 68 Years Waror Dates H Place of Death Hospital,Institution or Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing Mannerof Death EiNatural Cause Accident El Homicide OSuicide Undetermined ❑Pending W Circumstances Investigation WMedical Certifier Name Title 0 Joshua Starters NP Address 10421 State Route 40,Grenville Town,New York 12832 Death Certificate Filed Town Of Granville District Number Register Number Cit ,Town orVilla�e 5758 28 Burial Date Cemetery,Crematory or Facility Name 05ro512022 Pine View Crematory Entombment Address Cremation Query Town,New York EDonation ❑Removal Date Place Removed and/or and/or Held N Hold Address 0)OTransportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 5 Address gr Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/05/2022 Registrar of Vital Statistics AranyLiyuk.4f zlarts&gGchtmicaQysrgx4 (signature) District Number 5756 Place Town Of Granville I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition 3 S=t 2LPlace of Disposition "-Pi d0 titi 4.t Crc 11.+14 4-41 3 (address) W N CC (section) (l t number) (grew number) gG Name of Sexton or Person in Chaise o remises !?,Ti1 o I lJD'� z (please print) W Signature Z `f Title ©e ..tY& TD DOH-1555(07/18)pi of 2 V r • 3 t Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#