Bevins, Beatrice ail
NEW YORK STATE DEPARTMENT OF HEALTty t to
Vital Records Section Burial - Transit Permit
Name First Middle . Last Sex
Beatrice Elizabeth Bevins Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/15/2012 81 years War or Dates
}-- Place of Death Hospital, Institution or
Z City, To vi Street Address
ltl X Clens F� The Pines qt Glens.Fal s
Manner of"Deat natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
LU Circumstances Investigation
tu Medical Certifier , Name Title
Bernardo R Villajuan M D
Address
161 Carey Road Queensbury, Ny 12804
Death Certificate Filed District Number Register Number
City, To f iNf CX Glens Falls 5601 189
❑Burial Date Cemetery or Crematory
❑Entombment 08/16/2012 Pine View Crematorium
Address
Ell❑Cremation f ueen sbury NY 17804 _
Date Place Removed
Z ❑Removal and/or Held
and/or Address
t: Hold
Cif?
0 Date Point of
fiLi❑Transportation Shipment
G1 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury. N Y 12804
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
#C
LU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/16/2012 Registrar of Vital Statistics f..J0 ,� CA.)
(signatu
District Number Place
5601 GIPns Falls,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 8-1-1-11, Place of Disposition RN/VkkJ Cervvf rwk.-
a (address)
In
CC (section) `'(lot number (grave number)
0
Name of Sexton or Person in Charg of Premises A,it f� e"cif
(please print)
AO
Signature Title Oh,:VI1 1 0Q
(over)
DOH-1555 (02/2004)