Cleveland, Brenda /1613
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
,£ Name First Middle Last Sex
Brenda A.Cleveland Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/27/2018 55 Years War or Dates
Place of Death Hospital, Institution or
-: City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑Accident ['Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
`. Medical Certifier Name Title
William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 360
❑Burial Date Cemetery or Crematory
07/31/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
.7 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
il
❑Reinterment Date Cemetery Address
14, Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
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 remains described above as indicated.
Date Issued 07/30/2018 Registrar of Vital Statistics '6ertA Curtis(ECectronica1Cy Signed)
(signature)
flt 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:
la Date of Disposition 1j3)/Ig Place of Disposition '..,i,., ( p„�
(address)
(section) n{lot number) C h (grave number)
Name of Sexton or Person in Charge of Premises 1 A/r>> t 1P
7 (plea e print)
Signature 4 i Title c
(over)
DOH-1555 (02/2004)