Berg, Jason NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial Transit Permit
Name First Middle Last Sex
Jo son M. Be_g Male
Date of Death Age If Veteran of U.S. Armed Forces,
6/2 8/2 01 4 4 4 War or Dates
j- Place of Death Hospital, Institution or
Z EK9c Town fSMircigeIndian Lake Street Address 6333 NYS Rte.28/30
11.1
• Manner of Death Natural Cause 0 Accident El Homicide 0 Suicide riUndetermined Pending
it/ Circumstances Investigation
Medical Certifier Name Title
cl Donald L. Townspnd Coroner
Address
380 Rte. 28, Inlet, NY
Death Certificate Filed District Number Register Number
City, Town or Village Indian Lake 2053 3
❑Burial Date Cemetery or Crematory
7/1 /2014 Pine View Crematory
❑Entombment Address
®Cremation Que3nsbury, NY
Date Place Removed
Z Removal and/or Held
2❑and/or Address
F- Hold
CA
O Date Point of
GD? 0 Transportation Shipment
a by Common Destination •
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of FunerdOlilan110r Funeral Home 011 99
Address NYS -Rte. 30 Indian Lake, NY 12842
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
CC
ti
". Permission is he eby granted to dispose of the human ema'ns describ ye as indicated.
Date Issued 7//AO i ci Registrar of Vital Statistics titio
• (signature)
Pigl District Number 5 3 Place Oc9.-/1 -' L
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI• Date of Disposition 1-. --i`1 Place of Disposition ?Nal., (, fc.+
2 (address)
tii
VI
CC (section) (lot nu er) (grave number)
ta Name of Sexton or Person . Charge f Premises
Z vlease print)
rim Signature /". Title t-
(over)
DOH-1555 (02/2004)