Dickinson, Betty NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Middle Last
Name First SexFemale
4- Betty Jane Dickinson
Date of Death Age If Veteran of U.S. Armed Forces,
07/17/2018 99 Years War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide ri"-a Undetermined Pending
LU Circumstances Investigation
tu• Medical Certifier Name Title
i Philip Gara MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 34
T❑Burial Date Cemetery or Crematory
07/17/2018 Pine View Crematorium
4£0 Entombment Address
�, ®Cremation Fort Edward Town, New York
Date Place Removed
• Removal and/or Held
pr and/or Address
▪ Hold
E 0 Date Point of
cQ Transportation Shipment
a by Common Destination
.,,,1° Carrier
El Disinterment
Date Cemetery Address
▪ ,
A Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
rt': Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
A Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
Ull
a. Permission is hereby granted to dispose of the human remains described above as indicated.
t Date issued 07/17/2018 Registrar of Vital Statistics Aimee Mahoney tE1ei-tronica1ySigned)
511 (signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 7170 NS Place of Disposition .6.3.L. �t ew
t (address)
tO
EC (section) 1{0t number) (grave number)
Name of Sexton or Person in Char a of Premises `4 r+, L Sw.il
(plea print)
iii
44 Signature 6 Title irk''#
(over)
DOH-1555 (02/2004)