Bernard, Robert 6/9 NEW YORK STATE DEPARTMENT OF HEALTH # 6
Vital Records Section i Burial - Transit Permit
Name First Robert Middle A Last Bernard Sex Male
Date 04.190014 Age 82 earslf Veteran of U.S. Armed Forces,
y War or Dates 1954-1974
h• Place of Death Hospital, Institution or
W City, Towr� ll..- • Schenectady Street Address Ellis
0 Manner of Death A Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
W. Circumstances Investigation
Medical Certifier Name Title
Q Denis Manor M D
Addree846 Balltown Rd. Schenectady, New York 12309
Death Certificate a District Number Register Number
City, Town* Fi ll X Schenectady 4601 972
.al Date Cemetery or Crematory
11/10/2014
;i tombment Address
mation
Queensbury, N Y Pineview Crematorium
Date Place Removed
Z Removal and/or Held
t ❑and/or Address
H Hold
tri
0 Date Point of
N ❑Transportation Shipment
at by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Compassionate Funeral Care Registration Number
Name of Funeral Home 00364
Address 402 Maple Avenue, Saratoga Springs, Ny 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,'; Address
#r
ILI
P" Permission is hereby granted to dispose of the human remai descr' ed a ve a in . ated.Date Issued 11/10/2014 Re istrar of Vital Statistics 1 / 1, I1çoL/I7J1_/ (signature)
District Number 4601 Place Schenectady
F�-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI
) 'Date of Disposition j l A Lii� Place of Disposition ,�c ,,,_, ( ram'+'+
(address)
Ui
to
re (section) lot num (grave number)
Name of Sexton or Perso,(1 in Charge o Premises ) 44
Z //t (pie se print)
Signature /,� Title Cf' norp1
(over)
'1-1555 (02/2004)