Brandon, Ann Irr
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
-4.: Name First Middle Last Sex
Ann Elizabeth Brandon Female
▪ Date of Death Age If Veteran of U.S. Armed Forces,
June 29,2015 63 War or Dates n/a
: Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
Manner of Death I Xl Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
0 _s l 11,c�r- 1.
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Addre.::::: ak),„,„6,ss a 'N(N) 2�
:' r Death Certificate Filed District Number Register Number
. City, Town or Village Glens Falls, NY 5601 33
❑Burial Date Cemetery or Crematory
July 1, 2015 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
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O Date Point of
NI I 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
E. Remains are Shipped, If Other than Above
• Address
Ig
gi
Permission is her%/25egistrar
granted to dispose of the human remains desccrr'b- . . .ov as ' d ted.
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▪ Date Issued 0 of Vital Statistics �G�:✓� _.(signature)
District Number S60/ Place 6jt, , i., AI/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 7-I-IS Place of Disposition Rne v:f,..1 (.( 1v10..T@lr-,viv,
W (address)
CO
re (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises `1 �, ?n
`Z `�4 i (please print)
Signature i <�`"'" '- Title Ct-er.,c_4 ory 1454-
(over)
DOH-1555(02/2004)