Berson, Irene it
4
NEW YORK STATE DEPARTMENT OF HEALTH
...\
Vital Records Section Burial - Transit Permit
Name First
Middle Last Sex
Irene Berson Female
iti Date of Death Age If Veteran of U.S.Armed Forces,
12/08/2018 97 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
v' Manner of Death RINatural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
r Medical Certifier Name Title
Gwendolyn Morris-Dickinson PA
Address
", 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 579
❑Burial Date Cemetery or Crematory
12/11/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
ri Date Place Removed
❑Removal and/or Held
and/or Address
Hold
4
Date Point of
❑Transportation Shipment
-tom e by Common Destination
Carrier _
s ❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
• Address
• 53 Quaker Rd,Queensbury,New York 12804
47 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
n: Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 12/11/2018 Registrar of Vital Statistics pg6ertA Curtis(ECectronicaliySigned)
(signature)
£ District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
rr Date of Disposition 12,-i--iV Place of Disposition P jy�� Uj C,,,1) Cid't m44nls Y
er
(address)
ilr (section) (lot number) (grave number)
, Name of Sexton or erson in Charge of Premises wr,1^JO' S Ire,s
(please print)
Signature Title Gre,.41.a+o1
(over)
DOH-1555(02/2004)