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Burdick, Brenda L. NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Peihnit Bureau of Vital Records Name First Middle Last Sex Brenda L.Burdick Female Date of Death Age If Veteran of U.S.Armed Forces, 03/02/2021 75 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Hadley Town Street Address 4089 Rockwell Street, Hadley Town, New York 12835 W p Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined 1:1Pending W Circumstances Investigation WMedical Certifier Name Title CI Marena Euashachai DO Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Hadley 4558 6 EIBurial Date Cemetery,Crematory or Facility Name 03/03/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbtry Town,New York ❑Donation ElRemoval Date Place Removed and/or and/or Held H Hold Address 0 O. Date Point of U) 11 Transportation p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address C W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/03/2021 Registrar of Vital Statistics Pauline G Smead(Electronically Signed) (signature) District Number 4558 Place Hadley, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 3)5 Place of Disposition ?It 2 (address) W CC U) (section) ( t number) (grave number) ti Name of Sexton or Person in Charge of Premiset'^�� (please rint) W Signature Title llraY{TDlJ DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of ` delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#