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Brauser, Jerry William NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First A , Mid. • � Last Sex Jerry William Brauser Male Date of Death Age If Veteran of U.S.Armed Forces, 12/31/2021 71 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 139 White Birch Estates,Moreau Town,New York 12828 IJJ p Manner of Death ©Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined El Pending IJJ 0 Circumstances Investigation UJ G Medical Certifier Name Title Rita All NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Di tuber Register Number City,Town or Village Moreau 4562 65 ❑Burial Date Cemetery, rematory or Facility Name 01/03/2022 Pine View Crematory 0 Entombment Address ElCremation Queensbury Town,New York \ikNo.k... Donation : y; ZZ• Removal Date . Place Removed and/or and/or Held F Hold Address NO N ❑Transportation Date Point of s by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above 2 Address Q W EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/31/2021 Registrar of Vital Statistics Leeann etc ca6e(E(ectronica((ySigned) (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition I/412Z Place of Disposition .74.411..... Cat„- 11.1 (address) uJ W CC (sedan) / c(lot number) (grave number) SName of Sexton or Person in Charge of Premises ( ..)tnn4jZ (p46...._ se print)W Signature Title 0 rhAPa DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 4', n -7 ..., Receipt Human remains of delivered on , 20 . .. Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#