Berger, Shirley v •
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shirley R Berger Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/13/2017 80 Years War or Dates
Place of Death Hospital, Institution or
to City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 584
®Burial Date Cemetery or Crematory
12/02/2017 Pine View Cemetery
QEn
qtombment Address
❑Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
0al Transportation Shipment
' 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 Rd,Queensbury,New York 12804
'?' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/14/2017 Registrar of Vital Statistics s. ertAcurtis Esctronicalrysigned
(signature)
District Number 5601 Place Glens Falls, New York
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition
(address)
11
(section) (lot number) (grave number)
4
pp Name of Sexton or Person in Charge of Premises
(please print)
ITK
Signature Title
(over)
DOH-1555 (02/2004)