Gereau, Jeanne NEW YORK STATE DEPARTMENT OF HEALTH 1('°�.
Vital Records Section Burial - Transit Permit
Name First Middle t, st Sex Female
Jeanne B liereau
Date of Death Age ' If Veteran of U.S. Armed Forces,
3/19/2012 77 War or Dates no
Place of Death j Hospital, Institution or
OW Town SIX Queensbury Street Address 35 Old Mill Ln.
Manner of Death[J Natural Cause Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
CI John P. Stoutenburg MD
`� Address
Glens Falls,NY
Death Certificate Filed ! Districl�Nummbber Register Number
,' MC Town Queensbury
Date Cemetery or Crematory
El Burial 3/21/2012 Pine View Crematory
(� Address
LJ Cremation i Queensbury,NY
Date Place Removed
2 Removal ' and/or Held
and/or Address
— Hold
a Date Point of
fiti❑Transportation , Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
;, Name of Funeral Home Brewer Funeral Home, Inc 00211
Address
24 Church St., Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address
49
Permission is hereb granted to dispose of the human remains described move as indicated.
Date Issued* 4), Registrar of Vital Statistics ., Q , w '
(Si Lure)
District Number -1 Place I O( A..-N
I certify that the remains of the decedent identified above were disposed of in ac ardance ith this permit on:
1-
6 Date of Disposition 3-4)1 -)U/Z Place of Disposition '`Pv i e w Cre Ili& Or cv WI
2 (address)
W
N
(sec n (I t number) (grave number)
0 Name of Sexton or P rson in Ch.r•e of Premises ava list B unellC
z o,/;� (please print)
W Signature 4 I► /i Title C e.i#1 .4n/7
DOH-1555 (10/89) p. 1 of 2 VS-61