Brummer, Patricia A N EW YORK STATE DEPARTMENT OF H EALTH 051 Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patricia A Brummer Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/16/2023 69 Years War or Dates
F. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Ill
p Manner of Death ❑^ Natural Cause Accident III Homicide 0 Suicide Undetermined ❑Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
G Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 91
Burial Date Cemetery,Crematory or Facility Name
02/21/2023 Pine View Cemetery
Entombment Address
Cremation Queensbury Town,New York
nDonation
ZZ Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Q. Date Point of
(/) Transportation
Q by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
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
H Remains are Shipped,If Other than Above
i Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/17/2023 Registrar of Vital Statistics Megan Yolin(2/ctronicat Sand)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W (address) I
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N IL (section flat number)1 (grave number)
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BRUMMER
Owner
Richard Brummer and Daniel Brummer(son)
Address Plot
12 Dorlon Dr. Queensbury, NY 12804 Erie
Phone # Lot #
518-761 -4134 Cell- 845-216-1895 63E
Deed # Date
4371 2 .17.23
Cost Foundation Y - N
$700.00
Location
west-leClarie
South-Vacant
North- Tyner
East-Derosa
Remarks
I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE
PINE VIEW CEMETERY:
SIGNATURE: DATE:2 7 3
SIGNATURE: DATE i7 aoa3
Record of Interments
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Terms
BRUMMER (!......°11_,(Age:
NAME Patricia A Brummer 69
Lot Owner: Richard & Daniel Brummer
Lot# Erie 6 3 E Grave# 1
Case: Concrete
Died: 2 . 1 6 .2 3 Interred:2.21 .2 3
Funeral Home: Regan Denny Stafford
Cemetery: Pine View