Swanson, Brunella . 7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit ermit
. . Name First Middle Last Sex
.. Brunella L. Swanson Female
:• : Date of Death Age If Veteran of U.S. Armed Forces,
;;r April 11, 2016
86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
If Manner of Death x Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
William Cleaver
::. Address
100 Park Street,Glens Falls,NY 12801
: Death Certificate Filed District Number Register Num er
:: City, Town or Village Glens Falls 5601 1
❑Burial Date Cemetery or Crematory
April 13, 2016 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
r' Hold
Cl)
Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:? Permit Issued to Registration Number
°r." Name of Funeral Home Regan Denny Stafford Funeral Home 01443
:f ` Address
i'ri' 53 Quaker Road, Queensbury, NY 12804
;r:o.
i. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
' ' herebyr
:�r Permission i n ss o i s granted to dispose of the human remains described above as indicated.
4:, Date Issued '-i I 13 1 i , Registrar of Vital Statistics A.A. Ltii
(si ature)
rf � District Number 5601 Place Glens Falls 1 F y'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition NI/57I1, Place of Disposition SR(Ut.,, liar...
2 (address)
U)
re (section) ,(lot number) (grave number)
QName of Sexton or Person in Charge of Premises dK L J/Ai-
'Z /� /(please print)
Signature 6- .Z._ Title a F"l
(over)
DOH-1555(02/2004)