Bruno, Betty R. NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Betty R Bruno Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/08/2019 87 Years War or Dates
�.. Place of Death Hospital,Institution or
WCity,Town or Village Ticonderoga Town Street Address Heritage Commons Residential Health Care
p Manner of Death a Natural Cause Accident Homicide ❑Suicide El Undetermined Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
G Kristin Mack DO
Address
102 Racetrack Road,Ticonderoga Town,New York 12883
Death Certificate Filed District Number Register Number
City,Town or Village Ticonderoga 1564 70
Burial Date Cemetery,Crematory or Facility Name
11/09/2019 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
Hold Address
O
a Date Point of
N ❑Transportation Shipment
Q by Common
Carrier Destination
FjDisinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
Address
Q
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/08/2019 Registrar of Vital Statistics r!onyaM q ompvon(Ekctronu-af Sy-d�
(signature)
District Number 1564 Place Ticonderoga, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition Place of Disposition ,✓ ( rr�—
LU (address)
W
N (section) (lot number) (grave number)
C Name of Sexton or Person in Charge Premises W"r
/ ease print Z
W Signature Title
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) y 013063
Receipt
Human remains of t % - T r delivered on
Pine View Cemetery Representpilg the'fume home named on burial permit
Official Funeral Dlirectors Reg.or License#