VanCarples, Bertha NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Bertha E. Van Carpels F
Date of Death A�gge If Veteran of U.S. Armed Forces,
May 13, 1999 yU yrs War or Dates N/A
" Place of Death Hospital, Institution or
City,3T00WKKV8W Glens Falls Street Address Glens Falls Hospital
;. Manner of Death FX�Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Dr. Gerard F. Abess MD
Address
3 Iron Gate Center, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Glens Falls 5601 Z t-
Date Cemetery or Crematory
❑Burial May 13, 1999 Pine View Crematory
Address ---- --
®Cremation ueensbury rT 1.:, York 12804
Date TPlace Removed
Removal and/or Held
-• and/or Address
Hold
Q Date Point of
NQ Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Funeral Home 00022
Address
3809 Main Street Warrensburg, NY 12885
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 in to .
Date Issued 5/13/99 Registrar of Vital Statistics
Z24
(signature)
District Number 5601 Place Glens Falls City Clerk's Office, Glens Falls, N.Y. 12801
I certify that the remains of the decedent identified above were dispoo�sed_ of in accordance with this permit on:
W Date of Disposition-3 /�/-?� Place of Disposition /0/��
(address)
UJI
>� (section) (lot number) ( (grave number)
G9�j ,,�Name of Sexton or Person in Charge of Premises AZ&Az 114
z (please print)
Signature 144 Title o
DOH-1555 (10/89) p. 1 of 2 VS-61