Stokes, Bernetta tt 3oa
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Bernetta Marie Stokes Female
a°a Date of Death Age If Veteran of U.S. Armed Forces,
June 8,2011 87 , War or Dates
Z°r i Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
cr: Manner of Death [Xl Natural Cause I I Accident n Homicide 'Suicide i Undetermined Pending
I, Circumstances Investigation
W" Medical Certifier Name Title
gi Frances Bollinger MD
Address
Moreau Family Health So.Glens falls,NY
:',. Death Certificate Filed uistrict Number Register Number
_; City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
Pine View Crematory
❑Entombment Address
0 Cremation Quaker Road, Queensbury,NY 12801
Date ( Place Removed
Z I `Removal ` and/or Held
2 and/or Address
I— Hold
N
0 Date Point of
NI 'Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
WPermit Issued to Registration Number
aa; Name of Funeral Home Sullivan Minahan & Potter 01675
Address
407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
5l Address
Ili
Permission is hereby granted to dispose of the human remains described above as kndicated.
` Date Issued 1 1 0 1 i ty Registrar of Vital Statistics C. � ..�
::: (signature
; District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z DispositionPlace of DispositionW Date of i,�13't� p PALO{t'-) �+ry""'` v`iv
E (address)
W
W
re (section) 4 (l t number), (grave number)
QName of Sexton or Per on in Charge f Premises ft1t+(� r Sth440
Z 'please print)
W Signature71/r7L-1Title eW E'hpt i
(over)
DOH-1555(02/2004)