Bergquist, Edward if
NEW YORK STATE DEPARTMENT OF HEALTH 4.'—_ 0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edward M. Bergquist Male
Date of Death Age If Veteran of U.S. Armed Forces,
;rf January 11, 2013 94 War or Dates US Airforce
iPlace of Death Hospital, Institution or
City, Town or Village Glens Falls,NY Street Address The Pines Of Glens Falls
Manner of Death n Natural Cause Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation0. _
ut Medical Certifier Name Title
Bernardo Villijuan,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Regyser Number
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City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
January 15, 2013 Pine View Crematory
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
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O _ Date Point of
O.
_Transportation Shipment
p by Common Destination
_ Carrier
n Disinterment Date Cemetery Address
Ti Reinterment Date Cemetery Address
` > Permit Issued to Registration Number
<`fl Name of Funeral Home Regan& Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
f Permission is hereby granted to dispose of the human remains des ibe ab e a i icated.
Date Issued (Q/���`�.�a Registrar of Vital Statistics 4G
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition I- it,-a Place of Disposition .:.1.0uv Crbr+x'toI'w...
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(address)
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cc (section) 1 , lot number) c- (grave number)
QName of Sexton or Person in Charg of Premises `'r•A n�l
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SignatureTitle CEW1A�a(l.
(over)
DOH-1555(02/2004)