Bergeron, Lori NEW YORK STATE DEPARTMENT OF HEALTH r '
(oil 7
Vital Records Section Burial - Transit Permit
•
Name First Middle Last Sex
Lori Jean Bergeron Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/28/2013 57 years War or Dates
Place of Death Hospital, Institution or
5 City, TowieillaAkexx Glens Falls Street Address Glens Falls Hospital
W Manner of Death®yatural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined 0 Pending
Circumstances Investigation
Lu Medical Certifier Name Title
0 Frances C Rnllinger M D
Address
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Towfix3 i XX Glens Falls 5601 444
❑Burial Date Cemetery or Crematory
['Entombment Address
Pine View Cemetery
Address
Eli®Qiemation Queensbury. NY 12804
Date Place Removed
Removal and/or Held
and/or
Hold Address
O Date Point of
% Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01078
Address
136 Main Street South Glens Falls, N Y 12803
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
'„ Address
ILI
CC` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/30/2013 Registrar of Vital Statistics c>. y-\.9 (AJA/' f �t 2
(si ature)
District Number 5601 Place Glens Falls) N 9
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Iii Date of Disposition/, _3/- /j Place of Disposition % ivy V ,,,.J 04,..e,,.., 404
2 (address)
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CC -- (section) (lo umber) (grave number)
a Name of Sexton or ers in Ch. •- •f Premises
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(please print)
Signature Title (� z' Al-
(over)
DOH-1555 (02/2004)