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Bruckner, Edna 1 11zIg NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section • Burial - Transit Permit Name First Middle Last Sex Edna D Bruckner Female Date of Death Age If Veteran of U.S.Armed Forces, 03/20/2018 82 Years War or Dates _. Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation Manner of Death©Natural Cause 0 Accident Ei Homicide 11 Suicide nUndetermined El Pending Circumstances Investigation gip. Medical Certifier Name Title Gwendolyn Morris-Dickinson PA Address 170 Warren St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 144 El Burial Date Cemetery or Crematory 03/22/2018 Pine View'.rematory [I Entombment Address ®Cremation Queensbury, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of Ej Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address 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 r 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. 1m Date Issued 03/22/2018 Registrar of Vital Statistics cp6ertA Curtis(Electronically Signed) • (signature) y 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: Date of Disposition 3)Zi,ilg Place of Disposition EL,V.-- fr1-,010-- (address) (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises n� ^" ,., (pljase print) rr Signature [sf Title &Vivi N2_ (over) DOH-1555(02/2004)