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Breisch, Gloria May ,- _. g 9 0 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records f'. Name Firs1A ., _ ` Middle Last Sex Gloria May Breisch Female Date of Death Age If Veteran of U.S.Armed Forces, 01/10/2021 91 Years War or Dates H Place of Death Hospital,Institution or UJ Z City,Town or Village Queensbury Town Street Address 1264 West Mountain Road Apt.203,Queensbury Town,New York 12804 p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W U Circumstances Investigation GMedical Certifier Name Title Sharon Shannon NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 10 ❑Burial Date Cemetery,Crematory or Facility Name 01/12/2021 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town,New York if ❑Donation r.. ❑Removal Dote Place Removed F;, and/or and/or Held N Hold Address 0 m ❑Transportation Date Point of p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment Date Cemetery Address El Reinterment Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/12/2021 Registrar of Vital Statistics Caroline xf[egarIfe Barber(E(ectronically Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 1/)3)Zj Place of Disposition �....IL IJJ 2 (address) W . N CCnum tr.(section/ ber/ (grave number) Name of Sexton or Person in Charge of Premis " / , �. . i+y„Jin Z (pleas print) W Signature Title )1Nz+rc� vc DOH-1555(07/18)p 1 of 2 d Public Health Law Sec. 4145(2b) 01 4 t.0 6 Receipt Human remains of } delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#