Bray Jr., Dana Spencer NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dana Spencer Bray Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/17/2021 87 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
W
p Manner of Death E. Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
CI Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 75
Burial Date Cemetery,Crematory or Facility Name
03/22/2021 Pine View Crematory
Address
., Cremation Queensbury Town,New York
Donation
oZ El Removal Date Place Removed
and/or and/or Held
Hold Address
N
0
a Date Point of
t/) ❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/22/2021 Registrar of Vital Statistics CaroCnexkkgaraceBar6er(Electronicall 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:
�
Z Date of Disposition 3/13 Z( Place of Disposition
W
(ddress)
W
CC N
(section) /L7 (lot number) (grave number)
Name of Sexton or Person in Charge of P mises L/1 f `- ,16^ t
(pIkase print)
!iJ Signature — Title r °"14
DOH-1555(o7/18)p i 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#