Brennan, Beverly NEW YORK STATE DEPARTMENT OF HEALTH v n
Vital Records Section _ Burial - Transit Permit
Name First Middle Last Sex
Beverly Ann Brennan Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 13, 2015 76 War or Dates
i''';''''; Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of DeathiXir—I Natural Cause n Accident Homicide U Suicide U Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
bl.),IIIccMcos MO
Add s '
r\ rioi
Death Ch(ficatled District Number Register Number
City, Town or Village Glens Falls, NY 5601 Z5 2_
❑Burial Date Cemetery or Crematory
May 15, 2015 Pine View Crematorium
❑Entombment Address
CI Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
H Hold
co
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Li Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
,'_ Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafforuneral Home 01443
Address
``:`> 53 Quaker 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 abovet as indicated.
Date Issued 5/ /8`L5 Registrar of Vital Statistics V`� �/�1
(signature)
District Number 5-6 0 i Place 6 s, \ / pc
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition St Iy11C Place of Disposition em.u., 6-1�
2 (address)
W
Cl)
tY (section) lot qumber) (grave number)
pa Name of Sexton or Person in Charge of Premises .fii,
W � > (ple e print)
Signature Jf/�— Title itr
(over)
DOH-1555(02/2004)