Bertz, Shirley NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
ti{ti Name First Middle Last Sex
;:•j Shirley W Bertz Female
Date of Death Age If Veteran of U.S. Armed Forces,
r:; 03/05/2018 81 War or Dates n/a
iPlace of Death Hospital, Institution or
City, Town or Village South Glens Falls Street Address Home of the Good Shepherd
Manner of Death x Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
1 Madison Zuis, NP
1.• • Address
161 Carey Road Queensbury, NY 12804
'" Death Certificate Filed District Nu er Re ' ter Number
m• d
(
City, Town or Village Moreau•,❑Burial Date Cemetery or Crematory
03/12/2018 Pine View Crematory
❑Entombment Address
X Cremation Quaker Rd. Queensbury, NY
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
1Permit Issued to Registration Number
Name of Funeral Home R f egan Denny Stafford Funeral Home 01443
•i: Address
53 Quaker Rd Queensbury New York 12804
j?; Name of Funeral Firm Making Disposition or to Whom
i•••; Remains are Shipped, If Other than Above
Address
:::: Permission is hereby granted to dispose of the human r escrib ab ve as indicated.
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Date Issued 03/0 gl /a Registrar of Vital Statistics J�t,ta
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/ �/ / / (si ature)
District Number V � - Place 3 .)( I CVS !�._c igov 03l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 3-1)-i 3 Place of Disposition i i'1t v(44/ C,fsedpv.4 c)'
Waddress)
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0 (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises 3Q,C61c) ca' : -cc
Z (please print)
W Signature j Title CdfQ.M I'4r .
(over)
DOH-1555(02/2004)