Bean, Carolyn NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carolyn A. Bean Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 4, 2011 64 War or Dates
ZPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
31t Circumstances Investigation
' Medical Certifier Name Title
Christopher Hoy,MD
Address
Glens Falls,NY 12801
Death Certificate Filed strict Number Re ' tuber
City, Town or Village Glens Falls,NY 5601
Ei Burial Date Cemetery or Crematory
December 8, 2011 j Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
N Hold
0 Date Point of
NTransportation 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 Funeral Home j 01443
Address
`° 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
g Address
ry
tit
IX Permission is hereby granted to dispose of the human remains des ribedab yea dated.
Date Issued /W.e)G 0(/ Registrar of Vital Statistics t %k
a (signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 1 2/8/1 1 Place of Disposition pine V1 Pw Cpmptpr
W (add?ess)
co Mohican 48B 2
M (section) (lot number) (grave number)
QName of Sexton or Person i C arge of Premises Michael Cenicr
Z (please print)
tu
Signature '''.(;)\""":-PA-44 .12n Title Superintendent
(over)
DOH-1555(02/2004)