Belden Sr, Paul fl 17v
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ' Burial - Transit Permit
Name First Middle Last Sex .
Paul Scott Belden Sr Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/03/2013 81 years War or Dates
J Place of Death Hospital, Institution or
Z City, TowA0O/ip ON Glens Falls Street Address Glens Falls Hospital
0 Manner of Death❑piatural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
t;41 Circumstances Investigation
Medical Certifier Name Title
G Jennifer Donwan DO
Address
100 Park Street Glens Falls, Ny
Death Certificate Filed District Number Register Number
City, ToviCOCX/ittag6XX Glens Falls 5601 217
❑Burial Date Cemetery or Crematory
05/05/2014 Pine View Cemetery
❑Entombment Address
❑Qtemation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
0❑and/or
Address titt
Hold
8 Date Point of
85 Q Transportation Shipment
0 by Common Destination
lig Carrier
Disinterment Date Cemetery Address
Reinterment Date . Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan Funeral Home 01821
ni Address
11 Algonkin Street Ticonderoga, N Y
_: Name of Funeral Firm Making Disposition or to Whom
ii. Remains are Shipped, If Other than Above
Address
#I
Iu
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/05/2014 Registrar of Vital Statistics `A)ckA' cz,
(signature)
�
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
414 Date of Disposition 07 f f Place of Disposition u, ,w, ,,.Ar.
a (address)
ILI
CC (section) (lot number) (grave number)
0 Name of Sexton or Per on in Charge f Premises if-
, �`
( lease print)
LE Signature Title Cf2fMi'iif
(over)
DOH-1555 (02/2004)