Gulbrandsen, Theresa NEW YORK STATE DEPARTMENT OF HEALTH 4t 6-7 l
Vital Records Section Burial - Transit Permit
>; Name Fir tt Middle Last Se
i neresa Gulbrandsen Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/24/2013 85 years War or Dates
M- Place of Death Hospital, Institution or
City, i )br)XAWS Saratoga Springs Street Address 16 Jaipur Lane, Saratoga Springs, NY
IIIManner of Death Natural Cause ❑Accident El Homicide ❑Suicide D Undetermined ❑Pending
W Circumstances Investigation
141 Medical Certifier Name Title
i13 JJama L. Peacock Birsett M D
A6daoM9, Greenfield Center, N Y 12833
Death Certificate Filed District Number Register Number
City, TWAN-MAW Saratoga Springs 4501 390
❑Burial Date Cemetery or Crematory
09/26/2013 Pine View Crematory
❑Entombment Address
Cremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
0 ❑and/or
F Address
Cl) Hold
0 Date Point of
E>t Transportation Shipment
G by Common Destination
iiKii Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
:iiPermit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave., Saratoga Springs, NY
41 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
I
III
P` Permission is hereby granted to dispose of the human rema' = lade* indicat
Date Issued 09/25/2013 Registrar of Vital Statistics
(signature)
li District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
V t�rw�fo Place of Disposition t�� ram-.
l� Date of Disposition °I111(('S P ��
2 (address)
tt
ta
le (section) Potinff ber) (grave number)
clt :::t::e8t01
or Person in harge of Premises 0260101,
Title
(over)
•
DOH-1555 (02/2004)