Libecci, Beth i 1412
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Beth Ann Libecci Female
Date of Death Age If Veteran of U.S. Armed Forces,
03 / 21 / 2017 45 War or Dates N/A
}- Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death®Natural Cause Q Accident E Homicide 0 Suicide 0 Undetermined Pending
LSE Circumstances Investigation
fa Medical Certifier Name Title
i Farhana Kamal MD
ili
Address
100 Park St, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls , .co I 1 �
®Burial Date Cemetery or Crematory
03 / 24 / 2017 Pine View Crematory
0 Entombment Address
ii riCremation Queensbury
'`" Date Place Removed
Z ri❑Removal and/or Held
and/or Address
tit Hold
CA
0 Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
''Z` Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
mi LiiliR Permit Issued to 1 Registration Number
Name of Funeral Home Compassionate Funeral Care 1 00364
<< Address
Mi 402 Maple Ave., Saratoga Sp., NY 12866
Mi Name of Funeral Firm Making Disposition or to Whom
.14 Remains are Shipped, If Other than Above
2 Address
tip
t
? Permission is hereby granted to dispose of the human emains scribed above as indi ted.
iM Date Issued 0 / Registrar of Vital Statistics �l�
�� (signatu e)
Iiiiiiiill
`' District Number 5",$,,) / Place Gl s Falls , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
110 .
ILI Date of Disposition 3fr)!17 Place of Disposition -11140.-v- C'r+rtr,ttir11, ..
(address)
Ul
CC (section) /(lot number) (� (grave number)
0 Name of Sexton or Person ip Charge of Premis s [h nit-- TMAl#
(pie a print) •
Signature vl Title l l�`-m�lV�
•
(over)
DOH-1555 (02/2004)