Bernhoft, Robert 41-
NEW YORK STATE DEPARTMENT OF HEALTH `)36
Vital Records Section Burial - Transit Permit
4iz Name First � �� Middle A Last n ��� Sex ��
aJere
__<'. Date of Death Age If Veteran of U.S.Armed Forces,
>3 9/J,Z 013 2— War or Dates
Place of Death Hospital, Institution or
iii City, or Village Queen u Street Address
Manner Of Dea +latural Cause ciAccident 0 Homicide IDSuicide nUndetermined ri Pending
ill
Circumstances Investigation
Medical Certifier Name T
110
Address/C
= Death to Filed /-4 Dis - dumber Reg ter Number
City, own r Village U[1.1 S J cti (Dc I I I
<€ Burial Date ( Cemetery o Crematory
' ?❑Enfombmenf trl
/ p
� tr 0I 3
Address G
fJ ^:: remahon l�aic LvU /24 l�l U `,ems J)3 �U
Date Place Removed
`� i
Removal and/or Held //
"
�Hold/or Address
fli
Date Point of
fLA Q Transportation Shipment
by Common Destination
Carrier
ID Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
i
Name of Funeral Home may nott d �, a F-er �uneecc i For 01 110
s> Address t t La'Tccye+4 Stree
Queensbury New `/or lc 1a $oy
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
CC
iti
44 Permission is hereby granted to dispose of the human mlains described \blue as indicated.
_'ii d"L 4 Date Issue c' 1 )13 Registrar of Vital Statistics l �_ . � ��,
(signature)
District Numbers'(,S'") Place 0 u___r, C3( C
I certify that the remains of the decedent identified above were disposed of in ace d with this permit on:
• Date of Disposition 9/03 Place of Disposition ZIA
14.4 rtntct9Ew-
(address)
Ui
1 (section) (lot number) /' (grave number)
aName of Sexton or Person" Charge of P ises AILJ(ingif2 print)
::;::: Signa
ut ture L Title r`��/bj�(lt
(over)
DOH-1555 (02/2004)