Brand, Jeanne NEW YORK STATE DEPARTMENT OF HEALTH tt 1_10
Vital Records Section Burial - Transit Permit
L,�.:J Name First Middle Last Sex
' ' Jeanne Levine Brand Female
Date of Death Age If Veteran of U.S. Armed Forces,
{ April 20, 2012 88 War or Dates
I Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death Natural Cause Accident ❑Homicide n Suicide n Undetermined Ti Pending
Circumstances Investigation
Medical Certifier Name Title
nosI vn 5co\ 'MO
Address
VLe-Qx1Sk) D ,cI`t�
Death Certificate Filed j District Number Re ' ter Number
>-2 City, Town or Village Queensbury,NY 5657 c3 a
❑Burial Date Cemetery or Crematory
April 23, 2012 Pine View Crematory _
❑Entombment Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ri❑Removal and/or Held
2 and/or Address
H Hold
N
0 Date Point of
NEl Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
'' Address
53 Quaker Road, Queensbury, NY 12804
lfl+
<:> Name of Funeral Firm Making Disposition or to Whom
�' Remains are Shipped, If Other than Above
Address
1r,
Permission is hereby granted to dispose of the human remains described above as indicated.
:.,.; Date Issued (2 la Registrar of Vital Statistics �7� - S R�...-_,
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z f'
Date of Disposition 1(wit Place of Disposition R.. t v,,, �l,r .Aoci,_
(address)
W
(I)
CG (section) /�I (lot number) (grave number)
pName of Sexton or Person in Charge of Premises G h„fir �w�
LU /JI'4L.
(Please print)
Signature Title Oftlh4q-ram
(over)
DOH-1555(02/2004)