Myhrberg, Helen P 6 ...- 41- )C lo
NEW YORKSTATE DEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Helen P.Myhrberg Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/15/2023 97 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 88 Everts Avenue,Queensbury Town, New York 12804
111
p Manner of Death a Natural Cause Accident El Homicide Suicide Undetermined ❑Pending
VCircumstances Investigation
WG Medical Certifier Name Title
Sean Campanie NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number --Number
City,Town or Village 5657
Burial Date Cemetery,Crematory or Facility Name
® 09/21/2023 Pine View Crematory
Entombment Address
likremation Queensbury,New York
DDonation
Z❑Removal Date Place Removed
O and/or and/or Held
~ Hold Address
N
0
O. Date Point of
Cl)DTransportation
p by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
F— Remains are Shipped,If Other than Above
5 Address
2
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/18/2023 Registrar of Vital Statistics Caroliine.7afegard Bar6er(E/ctruni-aiSgned
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 1 in 73 Place of Disposition iI
IL
2 (address)
W
CC (section) (lot qumber) (grave number)
O Name of Sexton or Person in Charge of Premises Ir s r}
Z (plea print)
W Signature Title A f: PI VAL
DOH-1555(07/18)p 1 of 2
305
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#