Bergeron, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
%' Name First Middle Last Sex
r < Mary Theresa Bergeron Female
, r Date of Death Age If Veteran of U.S. Armed Forces,
July 29,2016 89 War or Dates NA
Place of Death Hospital, Institution or
;S City, Town or Village Glens Falls, NY Street Address Pines At Glens Falls
Manner of Death Natural Cause ❑Accident ❑Homicide n Suicide n Undetermined n Pending
tuki Circumstances Investigation
Medical Certifier Name Title
Melissa Decker,MD
2. Address
9 Carey Rd.Queensbury,NY
v Death Certificate Filed District Number Register Number
,f City, Town or Village Glens Falls,NY 5,,,001 22 4
❑Burial Date Cemetery or Crematory
August 1, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
• ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
P• ermit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
, Address
407 Bay Road, Queensbury, NY 12804
` ; N• ame of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above _
Address
Au
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Si 1 I I F Registrar of Vital Statistics C/)
•
(signature
District NumberE6 0 f Place 6 tz,„„S 6 I \ 5 M l7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ,,�� j1
Wl Date of Disposition S13(03 Place of Disposition TtMVurU C► �..
W (address)
N
0 (section) (lot number (grave number)
pName of Sexton or Person in Charge of Premises cc Jim*
Z (phse print)
W �/
Signature �/� ' Title (2 /441q.
(over)
DOH-1555(02/2004)