Heym, Betty 1 93z
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Betty A. Heym Female
,. Date of Death Age If Veteran of U.S. Armed Forces,
April 21, 2017 83 War or Dates
• Place of Death Hospital, Institution or
City, Town or Village Glens Falls, Street Address The Pines At Glens Falls
Manner of Death ' Natural Cause n Accident n Homicide Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Kenneth France,MD
Address
it 100 Broad Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 2 3
El Burial Date Cemetery or Crematory
April 24,2017 Pine View Crematory
El Entombment Address
0 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
Hold
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O Date Point of
Nri Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
{ Date Issued Li (2-S 07 Registrar of Vital Statistics
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District Number 56c) ) Places \S y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition //Z5 1n Place of Disposition cVRx� Zr/n,a'tcs�-._i
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re (section) (lot numb() (grave number)
p• Name of Sexton or Person in Charge of Premises /Ir,c .J+Mil If
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Signature 1C TitlerhA1Pin
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DOH-1555(02/2004)