Gannon, Betsy NEW YORK STATE DEPARTMENT OF HEALTH y
Vital Records Section Burial - Transit Permit
, Name First Middle Last Sex
; Betsy Jayne Gannon Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 31,2014 68 War or Dates
• ° Place of Death Hospital, Institution or
City, Town or Village Rochester Street Address Strong Memorial Hospital
Manner of Death I Xi Natural Cause Accident I I Homicide Suicide Undetermined Pending
� Circumstances Investigation
ti Medical Certifier Name Title
G1? Phillip C.Mongiovi MD
Address
601 Elmwood Avenue,Rochester,NY 14642
; '„®s Death Certificate Filed District Number Register Number
City, Town or Village Rochester 2700
❑Burial Date Cemetery or Crematory
August 4,2014 Pine View Crematory Entombment Address
I�I
E I Cremation Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
5 2and/or Address
i' Hold
N
O Date Point of
O. Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to HealtF �tration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 1Aon1Ccounty
of at Re ord` 01443
Address 2014
53 Quaker Road, Queensbury,New York 128011t6 0 1
:a° Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
orit Address Rochester,N 't
Permission is h re granted to dispose of the human r ains desc 'b above as indicated. A
Date Issued 1 Registrar of Vital Statistics�,�a►
�--
( nature)
• District Number 2700 Place Monroe County Office of Vital Statis cs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Of
� Date of Disposition 614 IA Place of Disposition ft,,,, 0_,..
W addr ss)
N
re (section) (lot nu r) (grave number)
p Name of Sexton or Person in Charge of Premises irtiaL „41-
iZ r, 1 (please print)
Signature . -- Title it
(over)
DOH-1555 (02/2004)