Berry, Laura L phi—)
NEW YORK STATE DEPARTMENT OF HEALTH BurialOD) - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Laura L.Berry
Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/22/2022 63 Years War or Dates
l— Place of Death Hospital,Institution or
WCity,Town or Village Fort Ann Town Street Address 51 Crawford Lane,Fort Ann Town,New York 12839
p Manner of Death Natural Cause Accident El Homicide li1Suicide nUndetermined []Pending
W
U Circumstances I 'Investigation
W Medical Certifier Name Title
CI Mark Hoffman MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Fort Ann District Number Register Number
City,Town or Village 5754 13
HBurial Date Cemetery,Crematory or Facility Name
05/24/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
0111 Date Place Removed
Removal and/or Held
H and/or
N
Hold Address
0
Date Point of
U) Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment •
Date Cemetery Address
Rei[]ferment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
ILI
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/24/2022 Registrar of Vital Statistics Barbara 9 Winched Signed)
(signature)
District Number 5754 Place Town Of Fort Ann
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH `�
Z Date of Disposition Sj3St 22 Place of Disposition i 4t tA‘..— 'dn.--
W (address)
W
ID
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of P2esi fit
Z lease print)
limwral.
W Signature _ Title
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) �� �,� .
Receipt
Human remains of delivered on , 20
Pine View Cemetery Re•resenting the funeral home named on burial permit
Official F eral Directors Reg.or License#
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