Belden, Michelle sS6
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section .,w,, Burial - Transit Permit
Name First Middle Last Sex
Michelle Marie Belden Female
Date of Death Age If Veteran of U.S. Armed Forces,
Auer_ 07, 2015 47 yrs, War or Dates no
,.,.... Place of Death Hospital, Institution or
• City, Town or Village Glens Falls ' Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident 0 Homicide ❑Suicide ❑ Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel Larson MD.
iIi Address
Death Certificate Filed Carey Rd. , Queensb1j rrct Wirfiber2804 Register
::<: City, Town or Village Glens Falls 5601 q d
Date Cemetery or Crematory
❑Burial Aug. 10, 2015 PineView Crematorium
Address
®Cremation Queensbury, NY. 12804
Date Place Removed
0 Removal and/or Held
,•• and/or Address
Hold
Q Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date • Cemetery Address .
Reinterment Date Cemetery Address
I Permit Issued to Registration Number
3 Name of Funeral Home Mason Funeral Home 01117
::::' Address
18 George St. , Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Olg Address
Permission is hereby granted to dispose of the human remains describes,' ove as indicated.
,ii Date Issued 08/0 7/1 5 Registrar of Vital Statistics (/QCKA.4-,.—Z, W= -"
(signature)
District Number 5601 Place City of Glens Falls, NY.
iiiiiiii
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IIDate of Disposition `d(1°f/6" Place of Disposition fi).(0..- alp--
a (address)
LU
N
ii (section) lot.num ) (grave number)
• Name of Sexton or Person in Charge of Premises i L WI-
(please print)
44 Signature Title hot Oa
(over)
DOH-1555 (9/98)