Bearor, Helen r , _. , g�
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helen R_ Bearor FPui. 1e
IR Date of Death Age If Veteran of U.S. Armed Forces,
12/24/2016 88 yrs_ _ War or Dates no
#- Place of Death Hospital, Institution or
ti City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
LIE Circumstances Investigation
tu Medical Certifier Name Title
James North MD.
Address
100 Park St_ Glens Fall NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 W .5
❑Burial Date Cemetery or Crematory
Dec. 27, 2016 PineView Crematorium
qg['Entombment Address
;;:;®Cremation Quaker Rd. , Queensbury, NY. 12804
Date Place Removed
Z El Removal and/or Held
and/or Address
H Hold
to --
0 Date Point of
iTransportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
gi,❑Reinterment Date Cemetery Address
iiiPermit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St. , P.O. Box 277, Fort Ann, NY 12827
igii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
in
Permission is hereby granted to dispose of the human remains des ribed above a created.
Iiiiii Date Issued 1 2/2 6/1 6 Registrar of Vital Statistics ��a�:;✓ ag-igli L2
(signature)
District Number ,S"(,,p/ 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:
Date of Disposition /2 2.7 Place of Disposition pfil e u,7)G fe a2a il o r
(address)
tip
tfl
CC (section) // (lot number) (grave number)
ci Name of Sexto r Pe on in Charge of Premises i� /, �1(_2G, , iced`
Zr � /� '?(please print)
Signature �(,'c`— Title G re'''
(over)
DOH-1555 (02/2004)