Reynolds, Beatrice NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
., Beatrice Reynolds Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 18, 2018 96 War or Dates
' Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 15 Angel Lane
ii Manner of Deathm
ni Natural Cause 0 Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
_: f Medical Certifier Name Title
_a„ William G. Rohan MD
Address
325 Main St., Hudson.Falls, NY 12839
le,- Death Certificate Filed ict�l.w er Regist�Number
City, Town or Village �� `—j
1E1 Burial Date Cemetery or Crematory
March 22, 2018 Pine View Cemetery —
❑Entombment Address
❑Cremation Quaker Rd. Queensbury,NY 12804
.. Date Place Removed
❑ Removal and/or Held
and/or Address
Hold Pine View Cemetery
a Date Point of
0,10 Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reii El interment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
,, Remains are Shipped, If Other than Above
Address
174
ri
® Permission is hereby granted to dispose of the humanreins described a 'e s indicated.
Date Issued3l l \ c3-C)t Registrar of Vital Statistics 1C�_. G
--- __.__. (signature)
District Numbe�j(9c Place lc u_---
-(' ca
I certify that the remains of the decedent identified above were disposed of in a cordance wit this permit on:
Cf Date of Disposition 03/22/2018 Place of Disposition Quaker Rd. Queensbury,N 12 4
(address)
W S. I. #2 #133 2
e (section) (lot number) (grave number)
0 Name of S ton or Person ' Charge of Premises
Connie Goedert
(please print)
.j Signature Title Cemetery Superintendent
frja GI-Lth,ek--- (over)
DOH-1555 (02/2004)