Bereza, John Iyb
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Bereza Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/26/2022 96 Years War or Dates
1.. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Address Glens Falls Hospital
pManner of Death RI NaturalCause ❑Accident ❑Homi e ❑Suicide ❑Undetermined ❑Pending
V
Circumstances Investigation
Ui Medical Certifier Name Title
CI Marcille Labban MD
Address ,
100 Park St,Glens Falls,New York 12801
Death Certificate Filed istrict Number Register Number
City,Town or Village Glens Falls 5601 127
❑Burial Date ' Cemetery,Crematory or Facility Name
03/01/2022 Pine View Crematorium
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Z ❑Removal Date Place Removed
and/or and/or HA
H Hold Address
N
0
n. Date Point of
N ❑Transportation
s by Common Shipment
Carrier Destination
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
21 Address
IC
W
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/28/2022 Registrar of Vital Statistics Megan Wolin(E(ectronicaffySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3111 U. Place of Disposition tc`L ,�----
2 address/
W
IC (section) 4(lot number) (grave number)
8 Name of Sexton or Person in Charge of Premises /)a', � ��il
z (pleas /
tU Signature j Title 4 ���M �
DOH-1555(07/18)p 1 of 2
p»� ,1-- ?•t f
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#