Edmunds, Bernice fi t1 Zl
' NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ABurial - Transit Permit
Name First Middle Last Sex
Bernice M. Edmunds Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 7,2015 80 War or Dates
I.. Place of Death Hospital, Institution or
Z• City, Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death IV Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
C. Michael Adams MD
Address
Glens Falls,NY 12801
Death Certificate Filed District Number Regi�stet imber
City, Town or Village 5601 `.^/1�(�
❑Burial Date Cemetery or Crematory
Entombment June 9,2015 Pine View Crematory
El Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
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O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
E. Address
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W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 61 (3 1 I 5 Registrar of Vital Statistics Q A 0,-SL
(signature
District Number 5601 Place Glens Falls /' V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 4Iio II r Place of Disposition ,ha. r.,,, `w-4as„
(address)
W
co
O (section) �j '(lot number) (grave number)
pName of Sexton or Person in Charge of Premises G`�,ito,Lr Sitr.Itt
Z I(please print)
W Signature X� is—. Title 11tcr+,¢914
(over)
DOH-1555 (02/2004)