Betz, Ruth NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
s
Name First Middle Last Sex
✓ Ruth Betz Female
Date of Death Age If Veteran of U.S. Armed Forces,
r : March 26, 2014 98 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
ig Manner of Death X Natural Cause I !Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
ri Mary C.Kilayko Dr.
Address
f 100 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Numb r
City, Town or Village Glens Falls 5601 I bo
El Burial Date Cemetery or Crematory
March 28, 2014 Pine View Crematorium
❑Entombment Address
❑X Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
O.• 'Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiii Permit Issued to Registration Number
:;:, Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Kii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
U Address
•
r Permission is her by ranted to dispose of the human r mains d scribed ove as ind' ate .
.:% Date Issued / Registrar of Vital Statistics
`7L
:X.
(signature)
• District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above w disposed of in accordance with this permit on:
W Date of Disposition -. 1/ Place of Disposition 1)1/,G V rk-v`��G—m/4
2 1 (address)
W
U)re
/
(section) � ber) (grave number)
GO Name of Sexton or ' r.oidle
of Premises ///
•
'Z , / pie-se print)
Signature ,rAir_IL'I Title A ,� "J
(over)
DOH-1555(02/2004)