Locke, Betsy NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
"M I Betsy N Locke Female
,.x.. Date of Death Age If Veteran of U.S. Armed Forces,
May 24, 2014 77 War or Dates
Place of Death
:; h Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel Larson
Address
r 9 Carey Road,Queeensbury,NY 12804
:; : Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 -5-'10
❑Burial Date Cemetery or Crematory
May 27, 2014 Pine View Crematorium
Entombment Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
i_ Hold
C')
0 Date Point of
wTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
;:;:;g Permit Issued to Registration Number
'•`.. Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
``r Address
i 407 Bay Road, Queensbury, NY 12804
•F•: Name of Funeral Firm Making Disposition or to Whom
I�r•.® Remains are Shipped, If Other than Above
Address
." 4
l Permission is hereby grant to dispose of the humanCemains scribed bove as indi ated.
Date Issued c O. 1 Registrar of Vital Statistics D -e.-7-1 ,� `
(signature)
:: District Number 5601 Place Glens Falls
HI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition S j.Q fiwiI/q Place of Disposition Vw-) t ;,9or,ho-
L (address)
W
co
c (section) Lip-
(lot numb (grave number)
GName of Sexton or Person in Charge of PremisesI.. �� t
Z (please print)
ul Signature s Title CO s�
r
(over)
DOH-1555(02/2004)