Betz, Mary NEW YORK STATE DEPARTMENT OF HEALTH R" 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary E. Betz Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 13,2011 87 War or Dates
Place of Death Hospital, Institution or
0City, Town or Village Fort Edward Street Address Fort Hudson Health Care Facility
° Manner of DeathUndetermined Pending
G X Natural Cause � �Accident Homicide Suicide
to Circumstances Investigation
ual• Medical Certifier Name Title
Philip J.Gara Jr.
Address
327 Broadway,Fort Edward,NY
Death Certificate Filed District Number Registgl Number
City, Town or Village Fort Edward 5755
❑Burial Date Cemetery or Crematory
January 17,2011 Pine View Crematory
Entombment Address
ID Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
H Hold
0 Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I.- Remains are Shipped, If Other than Above
2 Address
tit
Da
Permission is reb ranted to dispose of the human r nos described o e as i icated.
Date Issued / Registrar of Vital Statistic
(signs ure)
District N mber 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition 160 15, 2aii Place of Disposition
(address)
N
(section) (lot num r) (grave number)
Name of Sexton or Per on in Chargej•f Premises
/ (please print)
LU
Signature ! Title (11-E1 l .�6 —
(over)
DOH-1555 (02/2004)