Berg, Verdie NEW YORK STATE DEPARTMENT OF HEALTH
. ' 41 Lt It
Vital Records Section Burial Transit Permit
Name First Middle Last Sex
Verdie R Berg Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/04/2012 83 years War or Dates 1945-1947
14: Place of Death Hospital, Institution or
CitIliy, Toy��QRVgX Schenectady Street Address Ellis
Manner of Death atural Cause Ei Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
In Circumstances Investigation
tu Medical Certifier Name Title
CI Jamshaid A. Minhas M D
Address
2123 River Road, Niskayuna, N Y 12309
Death Certificate Filed District Number Register Number
City, Too XXXVKX BCX Schenectady 4601 708
❑Bur. 1 Date Cemetery or Crematory
❑ 08/09/2012 Pineview Crematory
tombment Address
Cremation Oueensbury, N Y
Date Place Removed
Z Removal and/or Held
❑and/or Address
E= Hold
tn
fl Date Point of
Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave., Corinth, N.Y. I g of
i> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ILI
`▪ Permission is hereby granted to dispose of the human re ain� r' d a e aji icated.
Date Issued 08/06/2012 Registrar of Vital Statistics LIE (
District Number 4601 Place Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
till Date of Disposition S-id`11 Place of Disposition ,r,,.40fwJ C i�.ti0r tub
2 (address)
Lu
L
CC (section) (lot number) (grave number)
ca Name of Sexton or Person in Charge of Premises � --r+3� 1` -it�1,,rt
2 (please print)
Signature /I"Ir'�"�' lis -- Title CUE pritlik.
(over)
DOH-1555 (02/2004)