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Brant, Dorothy # i5s NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Dorothy Lee Brant Female Date of Death Age If Veteran of U.S. Armed Forces, September 6,2013 79 War or Dates Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address 9-208 Regency Park North Manner of Death 0 Natural Cause n Accident ['Homicide []Suicide 0 Undetermined C Pending Circumstances Investigation Medical Certifier Name Title Suzanne Eppley MD Address " Death Certificate Filed District Number Register Nu ber :! City, Town or Village g Queensbury 5657 /1/ 61 ❑Burial Date Cemetery or Crematory September 9,2013 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road, Queeensbury, NY 12804 Date Place Removed ZZ ri Removal and/or Held and/or Address F' Hold (I) O Date Point of yLi Transportation Shipment p by Common Destination Carrier ` Disinterment Date Cemetery Address Ej Reinterment Date Cemetery Address '''' Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 0: Address %% 407 Bay Road,Queensbury,NY 12804 F Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address , Permission is hereby granted to dispose of the human re sins described abov s indicated. �'� JJ _fy Date Issued �'-4��1 Registrar of Vital Statistics ��(,(�/�. /% (signature) ,:-,./..;fr r District Number 5657 Place Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LU Date of Disposition 1/1113 Place of Disposition Zit.) Co ,._ W (address) CO O (section) /LA- lot n ber) S (grave number) z Name of Sexton or Person in harge of Pr mises e r1t+ (ple se print) W Signature Title C2 raQ (over) DOH-1555(02/2004)