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Brundige, Marion NEW YORK STATE DEPARTMENT OF HEALTH vtvi 1 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Marion A. Brundige Female Date of Death Age If Veteran of U.S. Armed Forces, August 28,2012 90 War or Dates Place of Death Hospital, Institution or _City, Town or Village Queensbury Street Address 175 Robert Gardens North Wi Manner of Death X'Natural Cause Accident n Homicide Suicide n Undetermined [ Pending Circumstances Investigation la Medical Certifier Name Title P Christopher Hoy,MD Address n 100 Park Street,Glens Falls,NY 12801 Death Certificate Filed District Number 'Register Number City, Town or Village Queensbury Lci _ I ❑Burial Date Cemetery or Crematory August 31, 2012 Pine View Crematorium ❑Entombment Address ©Cremation 21 Quaker Road,Queensbury,NY 12804 Date Place Removed ZC n Removal and/or Held and/or Address H Hold N O Date Point of Nri Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address ;wv Permit Issued to Registration Number .. Name of Funeral Home Regan& Denny Stafford Funeral Home 01443 Address 53 Quaker Road, Queensbury,NY 12804 ;ry, so' Name of Funeral Firm Making Disposition or to Whom *.; Remains are Shipped, If Other than Above Address re • Permission is hereby granted to dispose of the human e ains describe -a ove as indicated. Date Issued l_ icD � ��. + )d Registrar of Vital Statistics (signature) District Number CO.( s Place Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition ,,+��`� Place of Disposition jiwV t&. t ...rt0c tv,-. L (address) W Cl) tY (section) (lot number) r- (grave number) pName of Sexton or Person in Charge of remises A 11 ir Jtawif Z (please print) W Signature - -il Title Cite,n41-DA, (over) i DOH-1555(02/2004) I