Rist, Josephine r T
RI
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
'°` Josephine A RIST Female
Date of Death Age If Veteran of U.S. Armed Forces,
y 7/6/2 01 5 71 War or Dates no
i- Place of Death Hospital, Institution or
WCity, Town or Village Granville Street Address Haynes House of Hope
pManner of Death Natural Cause ❑Accident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
ui Medical Certifier Name Title
G John Stoutenburq M.D.
Address
Glens Falls, NY
4Death Certificate Filed D`�tn tuber Register Number
City, Town or Village Granville ` P
f❑Burial Date Cemetery or Crematory
;� 07/07/2015 Pine View Crematory
Entombment Address
EICremation Queensbury, NY
Date Place Removed
Z ri❑Removal and/or Held
and/or
Address
Hold
0 Date Point of
❑Transportation Shipment
Ei by Common Destination
q Carrier
Disinterment Date Cemetery Address
Wi
U 4
f.
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Brewer Funeral Home, Inc.
Name of Funeral Home 0021 1
Address
24 Church St. , Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
i
LU
114 Permission is hereby granted to dispose of the human remains describedp abovefl as indicated.
Date Issued 7 17/IS Registrar of Vital Statistics f pl w�.�cc4 )ye-c 2
(signal re)
., District Number Place
S'7610 Tot.A.nJ u F �A-Nvlc,u;'
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 1I g J IS Place of Disposition Z Li t;',.w44...,
5 (address)
W
N
W (section) (lot number) (grave number)
0 Name of Sexton or Person in Char of Premises ��' S -
ZA Obese print)
W Signature Title Of'" -
(over)
DOH-1555 (02/2004)