Harvey, Bertram s +- .
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
41 Name First Middle Last Sex
Bertram Eugene Harvey Female
,.' Date of Death Age If Veteran of U.S. Armed Forces,
12/25/2018 92 War or Dates Navy
�� Place of Death Hospital, Institution or
I City, Town or Village Granville,NY Street Address Haynes House Of Hope
Manner of Death Natural Cause ❑Accident I 1 Homicide ❑Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
12 Anthony Petracca,MD
Address
Glens Falls,NY
1 Death Certificate Filed District Number Register Number
3 City, Town or Village Granville,NY 5-7 S6 ''' 1
❑Burial Date Cemetery or Crematory
El Entombment December 27,2018 Pine View Crematorium
Address
1 Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
H Hold
(I)
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
, Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
AA
Date Issued la l a 6s o I Registrar of Vital Statistics
'signature)
District Number S'l S6 Place -"OWN o F G-RA J iU€
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition),,— .7,t/ Place of Disposition p;r V,{6, C(e,rrm }Gc y
Ili (a dress)
CO
(section) r (lot number) (grave number)
Q Name of Sexton or P son in Charge of Premises -eCi e Y ,fL-C
Z (please print)
Signature Title G/'e4,-•90r
(over)
DOH-1555(02/2004)