Dubrule, Jeffrey NEW YORK STATE DEPARTMENT OF HEALTH *` # `I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeffrey B. Dubrule Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 5, 2012 50 War or Dates
uv Place of Death Hospital, Institution or
City, Town or Village Granville Street Address Orchard Nursing& Rehab Center
Manner of Death X Natural Cause ' 'Accident Homicide Suicide I Undetermined Pending
US Circumstances Investigation
til
= Medical Certifier Name Title
. Sean Kimball,MD
Address
79 North Street,Granville,NY 12832
nz Death Certificate Filed District Number Register Number
City, Town or Village Granville .5-15(9 3g
❑Burial Date Cemetery or Crematory
❑Entombment December 10, 2012 Pine View Crematorium
Address
EI Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
2 H Removal and/or Held
O and/or Address
H Hold
N
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
s. Name of Funeral Home Regan& Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
N+ Remains are Shipped, If Other than Above
Address
i
tti
"Y Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Ja 1 I o la la, Registrar of Vital Statistics fcACI2& WA '
Nature
(sig )
District Number 5156 Place Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ili Date of Disposition IZ I Milt Place of Disposition 't►..eV't I C or;i
W (address)
N
te
(section) k
, (lot number) (grave number)
Z0 Name of Sexton or Person in Charge of Premises th lease print)
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Signature ... .4.5- Title Ce.f.t pryr)L
(over)
DOH-1555(02/2004)