Berge, Johanne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Johanne Berge Female
Date of Death Age If Veteran of U.S. Armed Forces,
Dec. 12 , 1998 92 War or Dates no
Place of Death Hospital, Institution or
City, Town or Villa Street Address 199 Circular Street, SS, NY .
Manner of Death Natural Cause Accident ❑Homicide ❑Suicide El Undetermined Pending
x
Circumstances Investigation
Medical Certifier Name Title
Allan Eisemann MD.
Address
Riverview896 Road rexford New York 12148
Death Certificate FiledSAU
District Number Register Numh?r
40
City, Town or Village � '
Date Cemetery or Crematory
❑Burial December 15, 1998 pine View Crematory
Address
x Cremation Queensbury, New York. 12804
Date Place Removed
Z ❑Removal and/or Held
... and/or Address
Hold
Q Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home William J. Burke & Sons Funeral "Home 00269
Address
628 North Broadway, Saratoga Springs, New York, 12866
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 rema s ed abov as i dicated.
Date Issued 12/14/98 Registrar of Vital Statistics j
(signature)
District Number Place AMTOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition o2i �V Place of Disposition
(address)
UJ
(section) (lot u-�m-�� r�j , l (grave number)
GName of Sexton or Person in Charge of Premises ,� �� ✓f l / /�'`4
(please print} � l e
Signature Title ��
DOH-1555 (10/89) p. 1 of 2 VS-61