Morris, Bertha M. # 3S0
NEW YORKSTATE DEPARTMENT OF HEALTH BUfId� - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Bertha M.Morris Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/13/2020 101 Years War or Dates
F Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death FRI Natural Cause Accident Homicide Suicide
C.) ❑Undetermined Pending
W) Circumstances Investigation
GMedical Certifier Name Title
Michael Miles MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 27
FjBurial Date Cemetery,Crematory or Facility Name
04/15/2020 Pine View Crematory
Entombment Address
10,11
Cremation Queensbury,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
I- Date Point of
N Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 701443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
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 04/14/2020 Registrar of Vital Statistics f7imeeMalroney(Electronrcaf Stgne4
(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:
H
Z Date of Disposition J1 Place of Disposition L (�v ,
W
2 (address)
W
Q (section) (lot number (grave number)
SName of Sexton or Person in Charge of remises kA
Z (P SeP
W Signature Title
DOH-1555(07/18)p t of z
{
Public Health Law Sec. 4145(2b) 013546
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing t e funeral home named on burial rtermit
Official Funeral Directors Reg.or License# ��