Brewster, Amy :ft
NEW YORK STATE DEPARTMENT OF HEALTH 357pVital Records Section i Burial - Transitermit
Name First Middle Last Sex
Amy Sue Brewster Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/04/7013 35 years War or Dates
M;- of Death Hospital, Institution or
a oCitaigG
XX Glens Falls Street Address park st lens falls n y 12801
ner of Death❑Natural Cause /� Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Timothy E. Murphy Coroner
Address
52 Haviland Ave Glens Falls, N Y 12801
De th Certificate Filed District Number Register Number
ity Tow iii XX Glens Falls 5601 238
Burial Date Cemetery or Crematory
Entombment 06/06/2013 • Pine View Crematorium
Address
Coemation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
H anHold Address
d/or
Cl)
V Date Point of
05 Q Transportation Shipment
Gs by Common Destination
Carrier
Q Disinterment Date Cemetery Address •
Li Reinterment Date Cemetery Address
Permit Issued to - Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
il Name of Funeral Firm Making Disposition or to Whom
. 1 , Remains are Shipped, If Other than Above
2 Address
IC
l
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/06/2013 Registrar of Vital Statistics W G-A,1v-\.g, W.,, -(daAAST
(signature)
District Number 5601 Place Glens Falls /iffy /.2 ?/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
I Date of Disposition (m f 1 I13 Place of Disposition 'I��ca Crtn,4 rt,,,,`
2
(address)
litif
CA
re (section) C/ of number) (grave number)
0
0 Name of Sexton or P rson in Char of Premises Se041.-
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g �S� r
(please Tint)
Signature Title CEC,1v TL72,
(over)
DOH-1555 (02/2004)