Brayton, Josepht V
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Nigi Name First Middle Last Sex
Jose i h C Brayton Male
Viis Date of Death Age If Veteran of U.S. Armed Forces,
December 29, 2016 85 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village Town of Queensbury Street Address Warren Center
cl
"`w Manner of Death
"� n Natural Cause n Accident n Homicide 0 Suicide niUndetermined 1-1 Pending
3firi
Circumstances Investigation
¢ Medical Certifier Name Title
`f°;` Roslyn Sorolof,MD
Aii Address
ON Gurney Lane Queensbury,NY 12804
Death Certificate Filed District Number Registe Number
City, Town or Village Town of Queensbury,NY E t. 1 ,-lLi
®Burial Date Cemetery or Crematory
❑Entombment January 5, 2017 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
C and/or Address
N Hold
0 Date Point of
N1-7
Li Transportation Shipment
as by Common Destination
Carrier
ri
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
til Permit Issued to Registration Number
Name of Funeral Home Re.an Denny Stafford Funeral Home 01443
Address
NO
53 1 uaker Road 1 ueensbur NY 12804
yd Name of Funeral Firm Making Disposition or to Whom
It Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human ins d • a e in 'cated.
FM
'" Date Issued �j— o—1lG Registrar of Vital Statistics �,(
(signature
District Number S(4,671 PlaceL-us.4
F- I certify that the remains of the decedent identified above ere disposed of in - this permit on:
ujDate of Disposition 1 /5/201 7 Place of Disposition Pine View •- - _ - , eueensbury, NY
W (address)
W Mohican 78E 1
W
(section) (lot number) (grave number)
p Name of S ton or Person in Charge of Pre ' Connie L. Goedert
Z (please print)
W
Signature rtL '..ecl,ctci, Title Cemetery Superintendent
t
(over)
DOH-1555(02/2004)