Evans, Betty )
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Betty G. Evans Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 14,2015 90 War or Dates
i.,, Place of Death Hospital, Institution or
Z. City, Town or Village T/O Warrensburg Street Address 219 Schroon River Rd.
p; Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
L,i Circumstances Investigation
ul Medical Certifier Name Title
ell Michael R.Bell MD
Address
Warrensburg Health Center,Main St.,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number D
City, Town or Village T/O Warrensburg 5660 /d
i Burial Date Cemetery or Crematory
Entombment September 18,2015 Pine View Cemetery
Ill Address
❑Cremation Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date j Point of
O.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date 1 Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1■- Remains are Shipped, If Other than Above
2 Address
1Y
'L:
11.° Permission is hereby granted to dispose of the human re d scribed above 'ndicated.
Date Issued 9/15/2015 Registrar of Vital Statistics g,e,ck(sig
District Number 5660 Place T/O Warrensburg,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 9/1 9/1 5 Place of Disposition Pine View Cemetery
2 (address)
W
CO Ondawa Plot Ext. 17A S
1Y (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Connie L. Goedert
Z / (Please print)
W Signature i Title Cemetery Superintedent
(over)
DOH-1555 (02/2004)