Portalatin, Nancy J. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nancy J. Portalatin Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/16/2020 74 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
p Manner of Death IXNatural Cause Accident Homicide Suicide Undetermined Pending
V Circumstances Investigation
111.I Medical Certifier Name Title
Q
Eric Santell NP
Address
131 Lawrence St,Saratoga Springs, New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 225
❑Burial Date Cemetery,Crematory or Facility Name
04/17/2020 Pine View Crematory
Entombment Address
Cremation Queensbury Town, New York
Donation
ZO Removal Date Place Removed
and/or and/or Held
f—Cl) Hold Address
O
(L Date Point of
CO) Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500, Lake Luzerne, New York 12846
Name of Funeral Firm Making Disposition or to Whom
f.. Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/17/2020 Registrar of Vital Statistics John Paul Franck(Electronically Signed)
(signature)
District Number 4501 Place Saratoga Springs, 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 /���esv Place of Disposition
W
M (address)
W
co
M (section) (lot number/ /grave number/
13 Name of Sexton or Person/4he of Premis r•
Z (please print/
W Signature Title
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 5 f
U -DJb.3
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#