Bereza, Stella G AkIA
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Stella G.Bereza Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/24/2023 94 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death II Natural Cause Accident El Homicide OSuicide Undetermined ElPending
W Circumstances Investigation
W Medical Certifier Name Title
O Philip Gara MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 10
Burial Date Cemetery,Crematory or Facility Name
01/27/2023 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
8❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
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
Address
CC
W
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/27/2023 Registrar of Vital Statistics Aimee G Mahoney(ECectronicaltySigned)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I 00 113 Place of Disposition - L ---.
2 (address)
W
O (section) ', . L (lot num r� (grave number)
0 Name of Sexton or Person in Cha/ emises
Z I (please print)
i�
W Title Signature (r O t
DOH-1555(07/i8)p t 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#