Hermens, Bernadette NEW YORK STATE DEPARTMENT OF HEALTH it /C .
Vital Records Section
` Burial - Transit Permit
Name First Middle Last Sex
Bernadette C. Hermens Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 20, 2012 93 War or Dates
Ili Place of Death Hospital, Institution or
W_ City, Town or Village Lake Luzerne Street Address 87 Northwoods Road
WManner of Death X❑ Natural Cause [IIAccident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W1 Medical Certifier Name Title
el- James North, M.D
Address
100 Broad St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number c
City, Town or Village
-" 0 Burial Date Cemetery or Crematory
May 23, 2012 Pine View Crematorium
['['Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
}_ Hold
63 Date Point of
❑Transportation Shipment
_ by Common Destination
Cr Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El Reinterment
- Permit Issued to Registration Number
, Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2'. Address
IX
tY.T; Permission is hereby granted to dispose of the human r a ris descr/ib atlas ,indicated.
_.7
Date Issued 5-a3-I a Registrar of Vital Statistics c. i� J� h-ci`�
(signature)
District Number�� Place - -zed-T .__
I certify that the remains of the decedent identified above were disposed of in accordancerd� with this permit on:
u Date of Disposition 3- Ct/tt Place of Disposition RL) 4_ (.r or 1 ul,,
(address)
W
01
re (section) — (lot number) (grave number)
0 Name of Sexton or Per on in Charge of Premises
�t11k +��
(please print)
W Signature r �, Title
(over)
DOH-1555 (02/2004)