Belden, Doris NEW YORK STATE DEPARTMENT OF HEALTH 4 Burial - Transit 1'ermit
Vital Records Section
Name First Middle Last Sex
Doris M Belden Female
Date of Death Age If Veteran of U.S.Armed Forces,
E. February 15, 2014 1 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death ID Natural Cause 0 Accident 0 Homicide Li Suicide ii Undetermined El Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Marvin Daviswitz, M.D. Dr.
0 Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Nu ylgr
City,Town or Village Glens Falls ..5601 /
❑Burial Date Cemetery or Crematory
February 18, 2014 Pineview Crematorium
❑Entombment Address
0 Cremation Quaker Road Queensbury, NY 12804
Z Date Place Removed
0 E Removal and/or Held
and/or Address ....�
i' Hold
is Date Point of
0 El Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
a0 Disinterment
D Reinterment Date Cemetery Address
-
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
1-
Name of Funeral Firm Making Disposition or to Whom
$• Remains are Shipped, If Other than Above
W Address
0.
Permission is her by ranted to dispose of the human remains,described above as indicated.
i
Date Issued a /y Registrar of Vital Statistics W Ci-y52 w-A"
(signature)
District Number ,5-601 Place Glens Falls,New York 61ft1/
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 02/18/2014 Place of Disposition Pineview Crematorium
2 (address)
tU
N
0 (section) i(lot number (grave number)
O Name of Sexton or Person in Charge of Premises 'Atli),it✓ .•;,,,,,it
W i
ease print)
ifi-
Signature Title Cgig PAW
(over)
DOH-1555 (02/2004)