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Commisso, Jason Michael �3 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jane Marie Bergmeier Female Date of Death Age If Veteran of U.S.Armed Forces, 01/21/2020 94 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc Q Mannerof Death ©Natural Cause 0 Accident Ej Homicide ❑Suicide Undetermined ❑Pending U Medical Certifier Name Title Circumstances Investigation thi C Philip Gara MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number =legiiit,r Number City,Town or Village Fort Edward 5755 Burial Date Cemetery,Crematory or Facility Name 01/22,12020 Pine View Crematory Entombment Address RICremation Queensbury Town, New York Donation z Date Place Removed �0 Removal and/or and/or Held f= Hold Address to Transportation Date Point of by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom IH Remains are Shipped,If Other than Above Address tll _ a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/22/2020 Registrar of Vital Statistics Aimee 91,1akoney(ECectronicaffy Signed (signature/ District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F 9 W Date of Disposition l3 a Place of Disposition rti� c a /address/ Ilt I (section) , (lot number/ (grave number/ Name of Sexton or Person in Charge of Premises 1Ma W11 /p ase print/ Signature �U� Title �►�" ID�C, DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013268 Receipt Human remains of delivered on , 20 Pine View Cemetery _. Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#