Bartline, Mary NEW YORK STATE DEPARTMENT OF HEAL«H r Burial - TransitPermit
Vital Records Section
Name First Middle Last Sex
Mary A. Bartline Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 7, 201 3 67 yrs . War or Dates No
14 Place of Death Town of Hospital, Institution or
City, Town or Village Elizabethtown Street Address Horace Nye Home
W Manner of Death 0 Natural Cause Accident Homicide El Suicide 0 Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Charles E. Moisan, Jr. M.D.
Address
81 Park Street, Elizabethtown, New York 12932
Death Certificate Filed Town of District Number / Sc3 __
Register Numbers
City, Town or Village Elizabethtown _
lig El Burial Date Cemetery or Crematory
QEntombment 08/08/2013 Pine View Crematory
Address
;Cremation Oueensbury, New York
Date Place Removed
3❑Removal and/or Held
and/or Address
h_ Hold
Ci)0 Date Point of
toilL L. Transportation Shipment
G by Common Destination
lEiiii Carrier
Disinterment Date Cemetery Address
= ElReinterment Date Cemetery Address
l Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
iiiiii 11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
to
Permission is her by ranted to dispose of the human e - s d scribed above as indicated.
Date Issued D Registrar of Vital Statistics Rikail------
(signature)
District Number //5 Place eV 2,.21 .-62,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI Date of Disposition i ritif F�u
t� Place of Disposition 4i.1 arKtOfw--
(address)
Ili
t)
ir (section) (lot nuJnber) (grave number)
Name of Sexton or Person in harge of Pre ' es A.A.46-- Ciii-itt
2 (plee print)
Signature Title Caihpa2
(over)
DOH-1555 (02/2004)