Brusaw, Helen i, II/3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit r ermit
,t Name First Middle Last Sex
Helen Brusaw Female
`>' Date of Death Age If Veteran of U.S. Armed Forces,
July 10, 2016 93 War or Dates 1944-1946
I
Place of DeathHospital, Institution or
City, Town or Village Glens FallsStreet Address Glens Falls Hospital
Manner of DeathnNatural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name TitleJennifer Donovan,MD
' % Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
' % City, Town or Village Glens Falls, NY 5601 3 L j
❑Burial Date Cemetery or Crematory
❑Entombment July 12,2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z IT❑Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
u) ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
` Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury, NY 12804
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 -7 / ( 1 / / 6 Registrar of Vital Statistics Ct..k Vv, ^�
(V'.
'.; (signature)
`< District Number C bo ) Place 6 S?�S S' p c
7
I certify that the remains of the decedent identified above were disposed of in accordance1 with this permit on:
W Date of Disposition 1114116 Place of Disposition 'L.ut,.� tr ur,--
W (address)
N
CL (section) dtCs
(lot number)( (grave number)
pName of Sexton or Person in Charge of Premises ru ,...)1n0440
Z `K�'O' 6 PiC.
(please print)"Signature Title
(over)
DOH-1555(02/2004)