Cleveland, Beatrice NEW YORK STATE DEPARTMENT OF HEALTH.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Beatrice ' L. Cleveland Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 11,2011 83 War or Dates
Place of Death Hospital, InstitutiorHuritage Commons Residential Health
Z City, Town or Village Ticonderoga Street Address Care
• Manner of Death X Natural Cause Accident I 'Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
O Glen Chapman MD
Address
PO Box 29,Old Chilson Rd,Ticonderoga,NY 12883
Death Certificate Filed District Number Register Num¢,rr
City, Town or Village Ticonderoga,NY 1564 tt/�/�''II
❑Burial Date Cemetery or Crematory
Entombment Address
14,2011 Pine View Crematory
Address
Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
H Hold
N
p Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment 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
H Remains are Shipped, If Other than Above
2 Address
rt
a
Permission is hereby granted to dispose of the human re ' s described aab�ove a dicated.
Date Issued 06-13-2011 Registrar of Vital Statistics \ U \
(sig tur
District Number 1564 Place Ticonderoga,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition (,-IS-(t Place of Disposition s Uaet_, Cinu e tt�ti
2 (address)
W
N
(section) (lot nun ) (grave number)
O• Name of Sexton or P son in Charg f Premises t P"Ktt
Z , (please print)
W Signature Title Ck ti I'y►11'tie
(over)
DOH-1555 (02/2004)