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Persen, Ema A.
_ /13Z NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Erna A Persen Female Date of Death Age If Veteran of US.Armed Forces, 10/15/2020 81 Years War or Dates Place of Death Hospital,Institution or City,Town or Village Chester Town Warren Street Address 61 Moffitt Road,Chester Town Warren,New York 12817 pManner of Death ©Natural Cause ❑Accident El Homicide Suicide Undetermined El Pending to Circumstances Investigation W Medical Certifier Name Title G Eileen Spinelli NP Address Carey Rd,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Chestertown 5652 12 DIBurial Date Cemetery,Crematory or Facility Name 10/16/2020 Pine View Crematorium ElEntombment Address ©Cremation Queensbury Hamlet,New York ElDonation F. ❑Removal Date Place Removed ▪ and/or and/or Held H Hold Address CO 0 Date Point of N Li• Transportation Shipment Q by Common Carrier Destination 0 Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/16/2020 Registrar of Vital Statistics Mindy Conway(E1 ctmnicalTy Signed) (signature) District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition /Q//7 J.J-cyo Place of Disposition .Q j/IR, Yjt,h) C �CAct�'G�(adress/ 2 1 W CC (section) (lot number) (grave number) 8 3'"� S Name of Sexton or Person in Charge of Premises v�'f rt. (P�print) W Signature /, _ I' Title C'r `'or , /' DOH-1555(o7/i8)p 1 of 2 Public Health Law Sec. 4145(2b) 0 1 t-12 r Receipt Human remains of delivered on ,/ 1 ," , 20 ` Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# �'