Braley, Mira NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
:tip: Name First Middle Last Sex
r Mira Evelyn Braley Female
r;. Date of Death Age If Veteran of U.S. Armed Forces,
r :: October 28, 2014 94 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 44 Williowbrook Road
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
1Medical Certifier Name Title
Dr.Paul R.Filion
Address
{12 Irongate,Glens Falls,NY 12801
i_s§:4; Death Certificate Filed District Number Register Number
s City, Town or Village Town of Queensbury 5657 d
❑Burial Date Cemetery or Crematory
October 30, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Zz i I Removal and/or Held
and/or Address
H Hold
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0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ri Permit Issued to Registration Number
rjr Name of Funeral Home ReganDennytafford Funeral Home 01443
x� Y
; Address
M 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 b e as indicated.
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r r Date Issued )(� I Registrar of Vital Statistics q �
• �: (signature)
District Number 5657 Place Town of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Lu Date of Disposition iCG (;j/jq Place of Disposition mi, (L.. Crc a✓v
W (address)
U)
CL
(section) nut:0 (grave number)
Z Name of Sexton or Person in Charge of Premises A*�,(lot nu,a .i J`
Z �Jj :. i (p/ease print)
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Signature `I �, Title CiwMdFati
(over)
DOH-1555(02/2004)