Bertram, Frank " ' it -771
NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section ::. Burial - Transit Permit
Name First Middle1111111t Last Sex
Frank Loring Bertram Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 1,2015 95 War or Dates Army
Place of Death Hospital, Institution or
• City, Town or Village Granville, NY Street Address Orchard Nursing & Rehab Centre
gi Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
gi Jennifer Hayes, MD
: 1 Address
Granville,NY
Death Certificate Filed District Number Register Number
City, Town or Village Granville, NY 5`1 sL 3
❑Burial Date Cemetery or Crematory
November 4, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F Hold
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0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
' Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
;:r•. 407 Bay Road, Queensbury, NY 12804
y.
Name of Funeral Firm Making Disposition or to Whom
*::: Remains are Shipped, If Other than Above
Address
�: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued IVDV. y y2015 Registrar of Vital Statistics 'c
(signature)
District Number 5 gar, Place —1—Ow c f 6 ,w; 1 IP UUU
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition Ii) Vic Place of Disposition ,u J C TO!1.0....e
2 (address)
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0 (section) ,n (lot numb (grave number)
QName of Sexton or Person in Charge f Premises l 4r,r r. 3r•u►rt1`-
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(please print)
WSignature Title (( 'btIDL
(over)
DOH-1555(02/2004)