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Bernat, Edward
..-. it z1 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit , , .fName First Middle Last Sex Edward Adam Bernat Male Date of Death Age If Veteran of U.S. Armed Forces, fi January 7,2015 86 War or Dates 4 : Place of Death Hospital, Institution or Z: City, Town or Village Bolton Street Address 247 Trout Lake RoadIll _ ti Manner of Death X Natural Cause n Accident n Homicide Suicide n Undetermined Pending Circumstances Investigation Medical Certifier Name Title Christopher D.Hoy Address 102 Park Street,Glens Falls,NY 12801 .£ Death Certificate Filed District Number�= 5.� Register Number City, Town or Village Bolton 50 0 Burial Date Cemetery or Crematory El Entombment January 8,2015 Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address Hold co 0 Date Point of y U Transportation Shipment `p by Common Destination Carrier n Disinterment Date Cemetery Address Reinterment Date Cemetery Address .. Permit Issued to Registration Number b: Name of Funeral Home Alexander-Baker Funeral Home 00037 Address Rs 3809 Main Street,Warrensburg,NY 12885 °a Name of Funeral Firm Making Disposition or to Whom E Remains are Shipped, If Other than Above 2 Address ,,a Permission is herebygranted to dispose of the human remai � p os descr bed ab e as mdi ated. •r=°• Date Issued i 7- / 5 Registrar of Vital Statistics 2r (signature) p District Number 3�0 0 Place Bolton I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition ii i tr i5 Place of Disposition Zits (",ctpt✓ 2 W (address) U) ciC (section) lot numb ) (grave number) Name of Sexton or Person in Charge of Premises lipi.. 6►41- Z (pl ase print) W Signature /� Title L12Fir1W (over) DOH-1555 (02/2004)