Tompson, Berta 21'?
NEW YORK STATE DEPARTMENT OF HEALTH` 8
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Berta Tompson Female
Date of Death Age If Veteran of U.S. Armed Forces,
04 / 16 / 2015 86 War or Dates
j4 Place of Death Hospital, Institution or Saratoga County Maplewood
ZCity, Town or illage Ballston Spa. Street Address Manor
0 Manner of Death®Natural Cause 0 Accident E Homicide 0 Suicide ri❑Undetermined �Pending
lijCircumstances Investigation
Lu Medical Certifier Name Title
0 Leonard Gelman MD
Address
20 Prospect St. #106, Ballston Spa., NY 12020
Death Certificate Filed District Number 6 Register Number
s Till City, Town o� a Ballston Spa. �Li 55
'<> Burial ate Cemot9ry or Crematory
>`:i DEntombment " c i --l lie. vItcD e no
Address Cremation 0/ Qt-ta K212 RCGA ateaA 5 bl-t ) l mf
i]ii-,
:::::
Date Place Removed
A ri Removal / / and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment ' Date ' Cemetery Address
€ Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc. 00364
•Iii Address
<<i 402 Maple Ave. Saratoga Sp. NY 12866
ip Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
it
Permission is her by granted to dispose of the human rema' cri 17_19s ' cated.
'< Date Issued if i7i Registrar of Vital Statistics
Mii (signal. e
District Number 11 a,0 Place Ballston Spa. , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W. Date of Disposition 'lV ii,fir Place of Disposition 4 Ca d;-'1
2 (address)
in
fE (section) A (lot number) (grave number)
CV
czt Name of Sexton or Person in Charge of Premises i('4 Sc
Z /I (0/ease print) •
Signature X.
Title *AWL
(over)
DOH-1555 (02/2004)