Larkin, Beverly N'EW Y02K STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Beverly L. Larkin Female
Date of Death ' Age If Veteran of U.S. Armed Forces,
10/29/2018 90 War or Dates
Place of Death Hospital, Institution or
Town dtXittiaje Sand Lake Street Address 33 Brookside Way Apt 25
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined n Pending
Circumstances Investigation
99 Medical Certifier Name Title
Dr. Michael Sikirica M.D.
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
Town o X I e Sand Lake 9//0 36
®Burial Date Cemetery or Crematory
November 2, 2018 Pineview Cemetery
0 Entombment Address
['Cremation Glens Falls,NY
ut Date Place Removed
0 Removal and/or Held
and/or Address
ffr Hold
:° d Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
39 ElReinterment Date _Cemetery Address
1
Permit Issued to Registration Number
Name of Funeral Home DeGraaf-B ce Funeral Home, Inc. 00436
Address
4392NY150, PO Box 275 West Sand Lake New York12196
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
' Address
tom.
y Permission is hereby granted to dispose of the human remains described above as indicated.
/D Registrar of Vital Statistics
Date Issued 3o�ao/4' 9� t��A-��'�V � '�
s (signature)
= District Number 9/6Q Place <4 1 /--:<--X-----
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
' Date of Disposition) 1 /2/201 8Place of Disposition Pine View Cemetery Queensbury NY
(address)
Mohican 64-H 1
(section)
(lot number) (grave number)
m&$ Connie L. Goedert
egb�t�lll�Yl (please print)
Name of xton or Person in ChargePremises
Signature Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)