Fifield, Bruce NEW YORK STATE DEPARTMENT OF HEALTH i V f X t
Vital Records Section Burial - Transit Permit
ig Name First Middle Last Sex
Bruce A. E; f_i_a_td Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 22, 2011 54 yrs, War or Dates no
} Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
t Q Natural Cause �Accident �Homicide �Suicide
Circumstances Investigation
la Medical Certifier Title
tU 'I�i1{E�hy Murphy, Coroner
C. Paul Bachman Mn_
Address
iiM
52 Haviland Ave_ , Glens Falls, NY. 12801
Death Certificate Filed District Number Register Number
MI City, Town or Village Glens Falls 5601 336
hi['Burial Date Cemetery or Crematory
July 25, 2011 PineView Crematorium
['Entombment Address
Mii[ Cremation Oueensbury, NY.
Date Place Removed
Z ❑Removal and/or Held
and/or Address
tit to
Date Point of
Q` Transportation Shipment
in by Common Destination
Eii Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
ini Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 0111 7
<< Address
18 George St. , Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
k Remains are Shipped, If Other than Above
2 Address
W.
,!` Permission is hereby granted to dispose of the human remains de Lia
cribeed above as ated.
Date Issued p� istrar of Vital Statistics �=
July 2 5, 2 U T� (signature)
1411 District Number 5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tLi Date of Disposition i-2 S-i( Place of Disposition at Ji i 61»a{ar4vv\--
2 (address)
lAi
CC (section) (lot nu er) (grave number)
CI Name of Sexton or P son in Charg of Premises i IN('A`pk* A 41-
(please print)
Signature Title CRP-M o'rL-
(over)
DOH-1555 (02/2004)