Grasse, Bernice Cu !p-
NEW YORK STATE DEPARTMENT CiF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Berniece Adeline Grasse Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 24,2015 97 War or Dates
t- tce of Death Hospital, Institution or
• t , Town or Village City of Johnstown Street Address Wells Nursing Home
p Manner of Death n Natural Cause I I Accident Homicide 'Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
John Glenn M.D.
Address
84 East State Street,Gloversville,NY 12078
Death Certificate Filed District Number Register Number
Town or Village City of Johnstown 1702 51
❑Burial Date Cemetery or Crematory
❑Entombment December 28,2015 Pine View Crematory
Address
x cremation Queensbury,NY 124 O
Date Place Removed
Z Removal and/or Held
and/or Address
�' Hold
Cl,
O Date Point of
g5Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ins scribed ove a indic ted.
Date Issued 12/16/15 Registrar of Vital Statistics
(signature)
District Number 1702 Place City of Johnstown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition /2-Z$,-/.f Place of Disposition p21Q uret.0 ere.me a
(addres )
y
(section) (lot number) (grave number)
Q Name of Sexton or Person ' Charge of Premises J tea. C •n�-�.�2
`Z (please print)
Signature Title L r¢.q'Iala
(over)
DOH-1555 (02/2004)