Ebert, Bertha Jane t /i7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Bertha Jane Ebert Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/31/2020 86 Years War or Dates
.... Place of Death Hospital,Institution or
Z City,Town or Village Milton Town Street Address 30510 Shenango Trail 10,Milton Town,New York 12020
WW Manner of Death
El Natural Cause ElAccident EI Homicide 1=I Suicide 1:1Undetermined ElPending
U Circumstances Investigation
0 Medical Certifier Name Title
Rodney Ying MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Ballston Spa 4561 59
Burial Date Cemetery,Crematory or Facility Name
11/03/2020 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
cs Eland/or and/or Held
Hold Address
(/)
0
d Date Point of
U) j Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/03/2020 Registrar of Vital Statistics Brenda9forue(E/ctronicaQSgnerl)
(signature)
District Number 4561 Place Ballston Spa, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition ��/3/70 Place of Disposition t Zj7ic
2 (address)
W
N
CC (section) (tot number)< (grave number)
0 Name of Sexton or Person in Charge of Pre i s i'� �A41
/' (plea print)
W Signature / Title l�
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 014171
Receipt
Human remains of delivered on , 20-
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#