Brummett, Deborah Mary NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Deborah Mary Brummett Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/14/2021 66 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address St Peters Hospital
IJJ
p Manner of Death El Natural Cause 1=1 Accident El Homicide El Suicide ❑Undetermined Pending
0 Circumstances Investigation
ILI G Medical Certifier Name Title
Benjamin Wind DO
Address
315 S Manning Blvd,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 200
❑Burial Date Cemetery,Crematory or Facility Name
01/21/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Tovyn,New York
▪Donation
2 Date Place Removed
O and/oral and/or Held
Hold Address
N
0
a Date Point of
N) Li Transportation Shipment
p by Common
Carrier Destination
0 Disinterment
Date • Cemetery Address
Reinterment
Date Cemetery Address
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
5 Address
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/20/2021 Registrar of Vital Statistics DDaniellesgTllesjnegkctronica(Signed)
(signature)
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit
Z
W Date of Disposition I�ZZ j 71 Place of Disposition
2 (address)
W
CC
N (section) (tfo timber) (grave number)
g Name of Sexton or Person in Charge of Prem. `Y�
please print/
IlJ Signature Title ( it1Z
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 01 4,4 0
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#