Eggleston, Betty ' NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Betty Adair Eggleston Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/26/2006 83 years War or Dates
Place of Death Hospital, Institution or
Z City, Town At0{ba1�XXXX City Of Glens Falls Street Address Glens Falls Hospital
Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Lti Circumstances Investigation
W Medical Certifier Name Title
Noelle Stevens M D
Address
100 Broad Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Town NeMagiXXXX City Of Glens Falls 5601 475
❑burial Date Cemetery or Crematory
09/30/2006 Pine View Cemetery
❑Entombment Address
❑Cremation Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
C and/or Address
I= Hold
O Date Point of
tL Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01194
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
1 , Remains are Shipped, If Other than Above
Address
Ce
f
Permission is hereby granted to dispose of the human remains de cribed abo e as ' is ted.
Date Issued 09/26/2006-- Registrar of Vital Statistics dlril _
(signature)
iiH District Number 5 60 , Place o S C1 11 S /i 2
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
at Date of Disposition 9/30/06 Place of Disposition PINE VIEW CEMETERY, QUEENSBURY NY
2 (address)
at
to HURON 11-A 2
(section) (lot number) (grave number)
C
Name of Sexton or Pers in h rge of Premises £ I C H A F I C F N T F R
Z (please print)
✓tC Signature Title SUPT .
(over)
DOH-1555 (02/2004)