Bradley, Jane NEW YORK STATE DEPARTMENT OF HEALTH # Z?
Vital Records Section ` , s( Burial - Transit Permit
* Name First Middle Last Sex
Jane Bradley Female
Date of Death Age If Veteran of U.S. Armed Forces,
iin May 05, 2 01 4 80 yrs. War or Dates no
1 Place of Death Hospital, Institution or
aCity, Town or Village Queensbury Street Address Stanton Nursing & Rehab. Ctr.
Manner of Death®Natural Cause ❑Accident El Homicide El Suicide �Undetermined �Pending
Circumstances Investigation
Medical Certifier Name Title •
0 Suzanne Blood MD.
Address
161 Carey Rd. , Queensbury, NY_ 13804
iii Death Certificate Filed District N tt R i ter Number
City, Town or Village Queensbury a
Date Cemetery or Crematory
❑Burial May 06, 201 4 PineView Crematorium
Address
:::: ®Cremation Queensbury, NY. 1 2804
Date Place Removed
❑Removal and/or Held
-- and/or Address
Hold
0 Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
la Address
gii P.O. Box 277, Fort Ann, NY. 12827
1iiii Name of Funeral Firm Making Disposition or to Whom
b"s. Remains are Shipped, If Other than Above '
OAddress
W
Permission is hereby granted to dispose of the human r ins described o e as indicated.
€€] Date Issued May p ti, 7 01 Registrar of Vital Statistics �C Q - ` ,
iiiiiiii (signature)
NI District Numbera0 Place Town of Queensbury, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition Shiiy Place of Disposition Zl L. Gee vi4OrUy--
2 (address)
LU
<R
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 6.r-1(w(^ {U
g (please print)
14 Signature 4Title OVEPIttV(
(over)
DOH-1555 (9/98)