Becker, Caroline NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
r Name First Middle ast Sex
��{tt:T� Caroline Marie Becker Female
:?;; Date of Death Age I eteran of U.S. ed Forces,
10 January 24, 2017 93 ar or Dates
{ Place of Death Hospital, Instituti or
• City, Town or Village Glens Falls Street Address Glens Falls Hospital
W.
Manner of Death X Natural Cause I 1 Accident I I Homicide Suicide Undetermined Pending
A1,1. Circumstances Investigation
M• edical Certifier Name Title
Asian Shaundry
Address
100 Park Street, Glens Falls,NY 12801
D• eath Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 ( _ )
•
❑Burial Date Cemetery or Crematory
January 26, 2017 Pine View Crematorium
Ill Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
N Hold
0
O Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r
Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 1 126 /ZO j"? Registrar of Vital Statistics (/`)c.K.A./InsL v),-/N _ J "v
(signature)
District Number 5601 Place Glens Falls /.1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z + '7 ,
w Date of Disposition 111)I I] Place of Disposition AInt tc"r+cric
W (address)
co
w (section) � (lot number) (grave number)
pName of Sexton or Person in Charge of Premises L`ti LieAltit�'
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Signature /� ,/ZCy Title (RE 4119/\
(over)
DOH-1555(02/2004)