Lebrun, Deborah Ann kb)Ti
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Deborah Ann Lebrun Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/11/2021 67 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 86 Montcalm Street APT A,Glens Falls, New York 12801
tp Manner of Death a Natural Cause 0 Accident El Homicide 0 Suicide ❑Undetermined El Pending
U Circumstances Investigation
W Medical Certifier Name Title
O Shannon Evelis PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 399
Burial Date Cemetery,Crematory or Facility Name
09/15/2021 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
f- Hold Address
0
C- Date Point of
V) j Transportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
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
Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/15/2021 Registrar of Vital Statistics 1Qo6ertindrew Curtis(Electronica16,5rgned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— ,D
WDate of Disposition q461,..., Place of Disposition p i n c' V:V 11 [R44104 ory
2 (address)
W
N CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises Jp,ty St ;rt S
(please print)
W I Signature . Title C. G,$+yf1 G�
DOH-1555(07/18)p t 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#