Belden, Barbara NEW YORK STATE DEPARTMENT OF HEALTH. . > , # 1
Vital Records Section Burial - Transit Permit
Name First Middle Last i Sex
Barbara Ann Belden Female
Date of Death Age If Veteran of U.S. Armed Forces,
Mi January 18, 2016 74 j War or Dates No
Iii4 Place of Death Hospital, Institution or
Town of
iiZ City, Town or Village Hague Street Address 9037 Graphite Mountain Rd
''4 Manner of Death Natural Cause Accident [-I [ I Homicide Suicide Undetermined n Pending
Circumstances Investigation
rij Medical Certifier Name Title
Bryan Smead M.D.
Address
11 Cross Street, Bolton Landing, NY 12814
Death Certificate Filed Town of District Number Register Number
City, Town or Village Hague 5653 i 1
I� ' Date ' Cemetery or Crematory
I— Burial January 20, 2016 pint., View Crematory
Address
'XI Cremation Queensbury, New York
ZDate Place Removed
0 n Removal and/or Held
•- and/Holdor Address
0
0 Date Point of
Nn Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date ' Cemetery Address
I I Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
111 11 Algonkin St. , Ticonderoga, New York 12883
iik Name of Funeral Firm Making Disposition or to Whom
'' Remains are Shipped, If Other than Above
Address
44
Permission is hereby granted to dispose of the hum remains described above as indicated.
iiiiig Date Issued 1 /2 0/2 016 Registrar of Vital Statistics , fl
(sign ture)
District Number 5653 Place Town of Hague
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- '}
W Date of Disposition //Zt/jto Place of Disposition gtV fw.! Cf+r►ton#.-
2 (address)
LU
to
ce (section) &lot number) (grave number)
AName of Sexton or Person in Charge of Premises 7/1to '�+ St -
g (please print)
Signature Title fib PIT/
(over)
DOH-1555 (9/98)