Tubbs, Eunice Jan 21 2UI1 2:44Mi brewer rimer rule'ai J,v-vw-._,-.� r-z_ -
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
{ `' Name First Middle Last Sex
'' Eunice E. Tubbs Female
Date of Death Age If Veteran of U.S.Armed Forces.
;• 1/20/2011 b9 War or Dates no
Place of Death Hospital, Institution or
. OW Town,o Lake Luzerne Street Address 37 Towner Road
Manner Of Death 1J Natural Cause Q Accident ❑Homicide 0 Suicide D Undetermined Q Pending
3t Circumstances Imrestigation
Medical Certifier Name Title
Mark Hoffman MD
Address
t' Glens Falls NY
>, e
Death Certificate Filed District Number ' Register Number
41.
K;_ own Lake Luzern 5656 ,
❑Burial Date 1/2011 Cem?rne v f Crew Creematory
me View
ss
Li Cremation Queensbury, NY
. Date Place Removed
c)E3 Removal and/or Held
••. and/or Address
Hold
Date l Point of
Transportation j Shipment
a by Common Destination
Carrier
:= 0 Disinterment Date Cemetery Address
o R®interment Date ' Cemetery Address
Permit Issued to • Registration Number
>$ Name of Funeral Home Brewer Funeral Home. Inc. 00205
A 24 Church St., Lake Luzerne,NY 12846
Name of Funeral Firm Making Disposition or to Whom
-s: Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the huma a na desert d abo a indicated.
/
a, Date Issued J- 42/--20// Registrar of Vital Statisti -
i'll District Number ccZ1.56 Place LL -e- A)Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition DAN IS')to)) Place of Disposition i'►.,� 1I i r� �cvh,ti fiu >�r..
(address)
1 CO (section) 4 . I (lot nu (grave number)
Name of Sexton or Person in Charge of emises r.Ap Ili r 4,41.
(please print) 1
04 Signature /4L Title (11 E MP roQ,
DOH-1555 (10/89) p. 1 of 2 VS-61