Bernsten, Marian NEW YORK STATE DEPARTMENT OF HEALTH f �?
Vital Records Section Burial - TransitPermit
Name First Middle Last Sex
.: Marian A. Berntsen Female
x'" Date of Death Age If Veteran of U.S. Armed Forces,
February 23,2014 93 War or Dates
of Place of Death Hospital, Institution or
Z City, Town or Village Johnsburg Street Address 106 4H Road
tz, Manner of Death X Natural Cause ' Accident Homicide Suicide I ]Undetermined Pending
tt1 Circumstances Investigation
Ait Medical Certifier Name Title
0_ Ellen Duprey PA
Address
',HHHN,Johnsburg,NY 12843
Death Certificate Filed District Number Register t5imber
City, Town or Village Johnsburg 5655
0 Burial Date Cemetery or Crematory
February 25,2014 Pine View Crematory
obillent Address
®Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
E Hold
cn
0 Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Li Disinterment Date Cemetery Address
I 1 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
F Remains are Shipped, If Other than Above
o Address
Air
-, Permission is hereby granted to dispose of the human re 'ns described above as in icated.
Date Issued ) -o)14-a6>1- Registrar of Vital Statistics
nature)
District Number 5655 Place Johnsburg
"3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tuDate of Disposition J p c,Ily Place of Disposition �„�dDe—) C.�e11ea'J..►
W (address)
W
W (section) I
(lot numbsF� (grave number)
p Name of Sexton or Pers n in Charge f Premises ,, .J1 -
z lease print)
W
Signature Title Ct g7o&.
(over)
DOH-1555 (02/2004)