Belfy, Bonnie NEW YORK STATE DEPARTMENT OF HEALTH 1 • '' ft 5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Bonnie Ethel Belfy Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 17, 2011 66 War or Dates
-147 Place of Death Hospital, Institution or
W,
City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death X❑ Natural Cause ElAccident 0 Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
fa Daniel Way, M.D Dr.
Address
North Creek Health Ctr Warrensburg, NY
Death Certificate Filed District Number RegnIer
City, Town or Village 5601
0 Burial Date Cemetery or Crematory
November 21, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zRemoval
0`❑ and/or Held
and/or Address
F Hold
CO` Date Point of
ai❑Transportation Shipment
01 by Common Destination
-C) Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
}-.; Remains are Shipped, If Other than Above
Address
te
.[i-
a Permission is hereby granted to dispose of the human remains a cr'beddpovdicated.
Date Issued // /r 2. // Registrar of Vital Statistics L e---
/ (signature)
District Number 5601 Place / ...v /--AA /)>7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Nob al ic4( Place of Disposition 1 fn .t1b ) Ci�h►olbiW—
(address)
W
re (section) (lot number) � G1 (grave number)
• Name of Sexton or Person in Charge o remises Aikfplj
V
lease print)
W Signature Title CQE f Ot
(over)
DOH-1555 (02/2004)