Cooke, Betty D
NEW YORK STATE DEPARTMENT OF HEALTH 4.
Vital Records Section Burial - Transit Permit
;fir:: Name First Middle Last Sex
`' Betty Lou Cooke Female
% Date of Death Age If Veteran of U.S. Armed Forces,
'I July 27,2017 93 War or Dates NA
1; Place of Death Hospital, Institution or
City, Town or Village Town of Queensbury,NY Street Address 24 Linette Lane Queensbury, NY
ilil
irj Manner of Death ❑X Natural Cause n Accident n Homicide n Suicide Undetermined n Pending
Circumstances Investigation
at Medical Certifier Name Title
-14 Glen Anderson PA
ei
gii Address
161 Carey Rd. Queensbury NY 12804
`''. Death Certificate Filed DistrictNumberr Number
Queensbury,giR
City, Town or Village Town ofNY
❑Burial Date Cemetery or Crematory
' j'- L Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
Wu Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Mil Permit Issued to Registration Number
lig Name of Funeral Home Regan Denny Stafford Funeral Home 01443
?l?%' Address
r< 53 Quaker Rd. Queensbury, NY 12804
fns$ Name of Funeral Firm Making Disposition or to Whom
ll;«: Remains are Shipped, If Other than Above
Address
I
Permission is hereby granted to dispose of the human re ains described ab indicated.�c r
iM
<:::,: Date Issued I Ic Registrar of Vital Statistics Q.
,, (signature)
< f District Number Place ) /� � U(' ?c &c a .
eisiI certify that the remains of the decedent identified above were disposed of in ac• dance ith this permit on:
W Date of Disposition /3///7 Place of Disposition 2)12U,'e ) (J +/
(add ess)
U)
O (section) (lot number) (grave number)
Q Name of Sexton or P ' Charge of Premises J .1;a,'(;a.sytc'di-e
Z (pleas/e print)
ul
WIGv ty
Signature Title Cr-z. /
(over)
DOH-1555(02/2004)