Farley, Betty NEW YORK STATE DEPARTMENT OF HEAL l
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Betty Caroline Farley Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 30, 2018 75 yrs. War or Dates n/a
{,. Place of Death Hospital, Institution or
W City, Town or Village Hudson Falls Street Address 264 Main St. , Apt. B-4
W Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name• Title
0/9-6//O ioo 7 /YI.D
Addres
Death Certificate Filed District Number Register Number
City, Town or Village Hudson Falls 57 .6 /3
<i DBurial Date Cemetery or Crematory
QEntombment July 02, 2018 PineView Crematorium
Address
®Cremation Queensbury, NY. 12804
Date Place Removed
Z Removal and/or Held
9.❑and/or Address�
Hold
0 Date Point of
to ❑
Transportation Shipment
C by Common Destination
gi Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St. , P.O. Box 277, Fort Ann,NY. 12827
el Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,y Address
Cr
i
` Permission is hereby granted to dispose of the human remain escribed above as indicated.
J ' `^
51 Date Issued July 02, 2 Q istrar of Vital Statistics ' L3C)C.- .tj-2-�_
^. (signature)
District Number mac'7a, Place VH .J� F s, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
la Date of Disposition 7/Z(tQ Place of Disposition 1,0,., CA.
2 (address)
fit
to
cc (section) lot number) (grave number)
0 Name of Sexton or Person in Charge f Premises filis
,-.4
zr (p se print)
: Signature Title CR 1&
(over)
DOH-1555 (02/2004)