Betz, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charles G. Betz Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 14,2011 92 War or Dates World War II
Y-+ Place of Death Hospital, Institution or
Z City, Town or Village Fort Edward Street Address Fort Hudson Health Care Facility
ul
Manner of Death I X'Natural Cause I I Accident Homicide Suicide I Undetermined Pending
E Circumstances Investigation
la Medical Certifier Name Title
Philip J. Gara Jr.
Address
c 327 Broadway,Fort Edward,NY
Death Certificate Filed District Number Regis Number
City, Town or Village Fort Edward 5755
❑Burial Date Cemetery or Crematory
Entombment 17,2011 Pine View Crematory
Address
0 Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z -Removal and/or Held
2 and/or Address
l' Hold
N
0 —
Date Point of
yTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
y 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
j Remains are Shipped, If Other than Above
S, Address
wa
�"1 Permission is h reb ranted to dispose of the human r ins described b ve as ' dicated.
IF,,: Date Issued/AP / Registrar of Vital Statisti
(signature)
; District Number 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed ofl in accordance with this permit on:
W Date of Disposition GRIJ1O 11011 Place of Disposition inL VfCon/ CrFi•r.c or i�
W (address)
CO
DC (section) (lot nu r) (grave number)
pName of Sexton or Perso in Charge •r Premises j r,;i--p ('-
Z , / I - �+�•r
(please print)
W
Signature ; - Title (YLt. Al ATQC
(over)
DOH-1555 (02/2004)