King, Bernard H 4- 17 11
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Bernard H King Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/10/2020 92 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Northumberland Town Street Address 4 Jacob Drive, Northumberland Town, New York 12831
pManner of Death Natural Cause 1:1Accident ❑Homicide I=1 Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
U
p Medical Certifier Name Title
Carl Sgambati MD
Address
3050 Route 50 203,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Northumberland Town 4563 18
-0 Burial Date Cemetery,Crematory or Facility Name
12/14/2020 Pine View Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
❑Donation
Z• Removal Date Place Removed
• and/or and/or Held
N Hold Address
0
n. 1-1 Date Point of
(I) ❑Transportation
$ by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Funeral Service 01444
Address
94 Saratoga Ave,S Glens Falls,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/14/2020 Registrar of Vital Statistics Denise D Murphy(ECectronica1ty Signed)
(signature)
District Number 4563 Place Northumberland Town, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ffII f
W Date of Disposition 12 SIN I ZO Place of Disposition
(address)
W
CC (section) (lot number) (grave number)
gName of Sexton or Person in Charge of Premises th r.; i-i,r3 viA4It
z �f (plea print)
w J l 1741'fid&TOP-
Signature � Title
DOH-1555(07/18)pi of 2
Public Health Law Sec. 4145(2b) J 1 4 2 R 9
Receipt
Human remains of delivered on , 20
{
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#