Berry, Louise NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Louise S. Berry female
Date of Death Age If Veteran of U.S. Armed Forces,
biO4.0c 78 War or Dates n/a
F Place of Death Hospital, Institution or
frXTown aI � Fort Edward Street Address Ft Hudson Res. Health Care
a Manner of Death®Natural Cause Accident 0 Homicide 0 Suicide Undetermined �Pending
tti Circumstances Investigation
tu Medical Certifier' Name Title
0 Thomas Kandora, MD
Address
319 Broadway, Fort Edward, NY 12828
Death Certificate Filed District Numb RegisftyNumber
tidy, Town 014601411 Fort Edward -,5- /
Burial Date Cemetery or Crematory
11/06/2006 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road , Queensbury, NY
Date • Place Removed
Z Removal and/or Held
9❑and/or Address
i= Hold
to
0 Date Point of
Cl. ❑Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date - Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home ' 01519
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
a Address
CC
ti!
Permission is he by granted to dispose of the human ains described above as in 'cated.
Date Issued/� 6)6,e) Registrar of Vital Statisti s 2
,---- (signature)
District Number , Place /69..4),/,-2 d / tie 4-_-,,,
"" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
ILI Date of Disposition 11/6/0 6 Place of Disposition PINE VIEW CEMETERY, Q U E E N S B U R Y NY
2 (address)
111
to HORICON 11-C 1
te (section) (lot number) (grave number)
Name of Sexton or Person in arge of Premises M I C H A E L GENIE R
(please print)
Signature 1 ► Title S U P T
(over)
DOH-1555 (02/2004)