Bertram, Ileene Lois (t C\
NEW YORK STATE DEPARTMENT OF HEALTH F. iarial - Transit Pe Lit
Bureau of Vital Records
Name First Middle Last Sex
Ilene Lois Bertram Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/07/2022 98 Years War or Dates
F„ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Ill
W Manner of Death 0 Natural Cause Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
O Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 618
Burial Date Cemetery,Crematory or Facility Name
12/12/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
Z Removal Date Place Removed
- and/or and/or Held
f-- Hold Address
CO
0
Date Point of
(f)❑Transportation Shipment
a by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
0 Reinterment
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
R
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/12/2022 Registrar of Vital Statistics Megan Wain(Efectronicaffy Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
Z Date of Disposition 12./Igl'jt Place of Disposition ...r1L cr;--
W (address)
W
to CC (sedgy // (lot number) (grave number)
Name of Sexton or Person in Cha a of Premises ( A eis ," tt
ease printl
z tiz my
al Signature Title
DOH-1555(07/18)p 1 of 2
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#