Brayman, Jane stil
NEW YORK STATE DEPARTMENT OF HEALTH a Vital Records Section Burial - Transit Permit
„dn, Name First Middle Last Sex
Jane L. Brayman Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 12,2012 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
tid
iz Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
bli Circumstances Investigation
tit Medical Certifier Name Title
David Foote,MD
Address
Glens Falls Hospital,Glens Falls,NY 12803
Death Certificate Filed District Number Regj t l�pmber
_. City, Town or Village Glens Falls 5601 ��, /I
LI Burial Date Cemetery or Crematory
October 15, 2012 Pine View Crematorium
❑Entombment Address
Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
C and/or Address
H Hold
N
0 Date Point of
O.
Transportation Shipment
6 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
F°®i! Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
':a`ei Name of Funeral Firm Making Disposition or to Whom
; , Remains are Shipped, If Other than Above
I Address
14=
tit
= Permission is hereby ranted to dispose of the human remains de ribed ab ve 'cated.
Date Issued D Ai 20/2- Registrar of Vital Statistics `
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W tw Date of Disposition fD-I(,-►1 Place of Disposition efts C 'dry
2 (address)
W
CO C (section) ,(lot number) (grave number)
pName of Sexton or Person in Cha a of Premises Ar,, JQ.x. ii
Z ____41._ (please print)
W Title Ctai� -0k
Signature
(over)
DOH-1555(02/2004)