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Bergstedt, Jan-Eric f' 3,5 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex ri Jan-Eric 0 Bergstedt Male _> Date of Death Age If Veteran of U.S. Armed Forces, r January 9, 2017 81 War or Dates ,; Place of Death Hospital, Institution or Z City, Town or Village Queensbury Street Address 20 Westwood Drive lu Manner of Death X Natural Cause I 'Accident 0 Homicide Suicide Undetermined Pending tl Circumstances Investigation t Medical Certifier Name Title Alicia Earley MD Address 161 Carey Rd.,Queensbury,NY 12804 Death Certificate Filed Dki.strict tuber Regist umber City, Town or Village Queensbury Lo S fl ❑Burial Date Cemetery or Crematory January 11, 2017 Pine View Crematory ❑Entombment Address ❑x Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held O and/or Address H Hold cn O Date Point of NTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address Sr < Permission is her by granted to dispose of the human,remains described above as indicated. Date Issued V l l c l Registrar of Vital Statistics--- ° >n—L------ (signature) District Numbe .-) Place Queensbury I certify that the remains of the decedent identified above were disposed of inkaccordance with this permit on: w Date of Disposition I/,'l i'1 Place of Disposition 't�n�vicw) 6 `©t'i,- 2 (address) W cn (section) // lot number) (grave number) pName of Sexton or Person in Charge of Premises /iu%) r- 4�tixt if Z /� (�ease print) WISL [�[ Title Signature 0,:i Mil 102 (over) DOH-1555(02/2004)