Brunza, Teresa it- t
3�
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iiiii Name First Middle Last Sex
Teresa Brunza Female
e x
Date of Death Age If Veteran of U.S. Armed Forces,
e x
May 21, 2016 55 War or Dates NA
▪ Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
,p Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
i�i Circumstances Investigation
Medical Certifier Name William Cleaver MD Title
gi
Address
s.• : 100 Park Street, Glens Falls,NY
Death Certificate Filed District Number nay
Regis _rkber
i
Cty, Town or Village Glens Falls, NY 1 U
❑Burial Date Cemetery or Crematory
May 26, 2016 Pine View Crematory
❑Entombment Address
❑x Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
O.
• Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Heritage Funeral Home FH-728
▪•... Address
iiiii 1755 Telstar Drive Colorado Springs, CO 80920
Name of Funeral Firm Making Disposition or to Whom
►+ Remains are Shipped, If Other than Above
Address
gi
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5j 1 2 Cs 1 (6 Registrar of Vital Statistics LN)C ;v1 _L_LJ-cl..1/4V'7h
:•.:."
(signature,
• District Number (- ) Place C ��,�S. F-Gl 11 Si Cr
▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition &(21(IG Place of Disposition Zil i.- C
2 (address)
W
U)
O (section) (lot num A (grave number)
p b )Name of Sexton or Person in Charge of Premises Zit,,l
Z lease print)
W
Signature Title 1iz j r►� 1�2
(over)
DOH-1555(02/2004)