Bertelli, Patti Ann .k4 41- -1Z5-
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Patti Ann Bertelli Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/09/2022 67 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Argyle Town Street Address 18 Primrose Lane,Argyle Town,New York 12828
LIJ
O Manner of Death El Natural Cause Accident 0 Homicide Duicide Undetermined riPending
UJ
U Circumstances Investigation
W Medical Certifier Name Title
O Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Argyle District Number Register Number
City,Town or Village 5750 51
RBurial Date Cemetery,Crematory or Facility Name
09/13/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
[]Donation
0❑Removal Date Place Removed
and/or and/or Held
I Hold Address
N
0
a. Date Point of
Cl)[]Transportation
El Common Shipment
Carrier Destination
O
Disinterment
Date Cemetery Address
C Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
"S Address
CC
Ill
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/12/2022 Registrar of Vital Statistics She[Cey Mckernon(ECectronicaltySigned)
(signature/
District Number 5750 Place Town Of Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 9I31 R. Place of Disposition ... ,AAVi•—• sl{-dr
ili
2 (address)
W
NCC (section) i (lot number) (grave number)
S Name of Sexton or Person in Charge Premises
(p se print)
Z r
W Signature Title ` reAtmp
DOH-1555(07/18)pi of 2
OO1_6 23L
Public Health Law Sec. 4145(2b)
Receipt
Human remains of - delivered on - , 20 7 Z.
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#