Irish, Betty NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Betty G. Irish Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 10, 2016 95 _War or Dates NA
Place of Death 1Hospital, Institution or
: City, Town or Village Glens Falls, NY Street Address The Pines At Glens Falls
. , Manner of Death LXI Natural Cause I [Ac 'dent Homicide Suicide I. Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
r
Melissa Decker MD
�• # Address
2.�1 9 Carey Rd.Queensbury,NY
'� Death Certificate Filed _ District Number ocoCh Register Number
j i 2� City, Town or Village �-��en`� Fall � � �y 7
❑Burial Date Cemetery or Crematory
2/16/2016 Pine View Crematory
❑Entombment Address
CI Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ [ I Removal and/or Held
and/or Address
H Hold
W
Q; Date Point of
N Transportation Shipment
p by Common Destination
Carrier
[ Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
• Permit Issued to Registration Number
fr Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
A'; Address:•: 407 Bay Road,Queensbury, NY 12804
Yti.
n? Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
itg
Permission is hereby granted to dispose of the human remains des ibed abo e as Indic ted.
Fes
Date Issued OD (� __61 Ip Registrar of Vital Statistics / `1J , j /`"�
•, 1 (signature)
' _'
�;.ti District Number ��Gy { Place F., �'`
HI certify that the remains of the decedent identified above were di:.osed of in accordance th this permit on:
Z
W Date of Dispositions./!5f I K Place of Disposition 9,"it v,&v) c rtrvIcitcc y,
2 (address)
W
U)
X (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Ot,n1 1Y ii.,;`LS
Z (please print)
1.11
Signature l Title C,,Cc,rvor
(over)
DOH-1555(02/2004)