Bernhard, Beatrice 24/2017 13:55 15183;3377121 GORDON C EMERICK RAGE. 1411
4EW YORK STATE DEPARTMENT OF HEALTH 5114
Vital Records Section Burial - Transit Permit
a Name First Middle LastSex
Botho = Bernhard Female
1 Date of Death Age If Veteran of U.S, Armed Forces,
07/23/2017 96 years War or Dates
Place of Death Hospital, Institution or
EXPrown or Ifilkik)1X Clifton Park Street Address Schuyler Ridge Residential Health Care
Manner of Death Li ra
Natural Cause ri Accident 0 Homicide L3 Suicide ri Undetermined CIPending
1-4 Circumstances Investigation
q
t Medical Certifier Name _
Title
Renu Gupta Physician
,,i& Address
VA:,; ;644 untario St. echoes, N Y 12047
itP
itie Death Certificate Filed District Number Register Number
igitiOtrown or imp Clifton Park 4552 91
qi-0 Burial Date Cemetery or Crematory
07/25/2017 Pine View Crematory
p LIEntornbment Address
2Cremation Queensbury, N Y
Date Place Removed
ri Removal and/or Held
"-"I and/or Address
Hold
to
Date Point of
ID Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
:a u
,k..„r-i
Reinterment Date Cemetery Address
t---1
•;, , Permit Issued to Registration Number
I'S Name of Funeral Home Barton-modermott Funeral Home 00141
wi-
Address
9 Pine St.,Chestertown, Ny 12817
.:0
Name of Funeral Firm Making Disposition or to Whom
it Remains are Shipped, If Other than Above
al Address
at
w
IL
Permission is hereby granted to dispose of the human resins d scribed a ve as indicate
,!t Date Issued 07/24/2017 Registrar of Vital Statistics
gt z (signature)
District Number 4552 Place Clifton Park L
I certify that the remains of the decedent identified above were disposed of in accordanco with this permit on:
W Date of Disposition -7/257? Place of Disposition 1),>ie vi-di.t) re ,,,4),r./
aoddreasy
,v01
(section) (rot tymber) (grave number)
0 Name of Sexton or P son inharge of Premises i vt.. I r-6(4,1 64:-"Aia...zhe
Z (pieese print)
e
signotur --
-- 1% Title 6-/-a-i-nale
i., (over)
DOH-1555 (02/2004)