Brown, Jacqueline Lou (LF)
NEW YORK STATE DEPARTMENT OF HEALTH i Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jacqueline Lou Brown Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/06/2022 80 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 37 Willow Road,Queensbury Town,New York 12804
,p Manner of Death aNaturalCause Accident Homicide Suicide FlUndetermined ❑Pending
U I—ICircumstances Investigation
W Medical Certifier Name Title
C3 Frances Bollinger MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 128
Burial Date Cemetery,Crematory or Facility Name
09/08/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
❑Donation
g❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0
O. Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
I— Remains are Shipped,If Other than Above
E Address
Et
uJ
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/08/2022 Registrar of Vital Statistics Caroline Jfildegarde Barber(ECectronicalTySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition q—/Q-ZiraL Place of Disposition ,4Q i1,4 Cresta-teri
2 (address)
uJ
CC (sedionl (lot number) (grave number)
� 11
8 Name of Sexton or Person in Char of Premise4 ea yin�3nJ� (please
Z
W Signature ., al/ Title 0&rec. o r
DOH-1555(07/18)p 1 of 2
016
222
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#