Beswick, Mildred NEW YORK STATE DEPARTMENT OF HEALTH r 1 * to Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mildred E. Beswick Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 27,2012 80 War or Dates
PI- e of Death Hospital, Institution or
own or Village Glens Falls Street Address Glens Falls Hospital
anner of Death Undetermined Pending
°Q� X Natural Cause Accident Homicide Suicide n
.41 Circumstances Investigation
u' Medical Certifier Name Title
Frances C.Bollinger
Address
100 Broad Street,Glens Falls,NY 12801
: Death Certificate Filed District Number Register Number!`
it Town or Village Glens Falls 5601 ri-
❑Burial Date Cemetery or Crematory
_November 28,2012 Pine View Crematory
Entombment Address -
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
OZ l i Removal and/or Held
and/or Address
H Hold
N
O Date Point of
5 n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
pi Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
.- Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
'Xi Address
• Permission is h reby granted to dispose of the human remains escribed,above as indi•ated.
Date Issued 1( c3�/ Registrar of Vital Statistics /'T z ems% 0.27-c
(signature)
District Number 5601 Place Glens Falls /Ay /.20/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition J/a�/Z Place of Disposition Poliie.Alt-}.� C�e
2 (address)
W
N
W (section) 4tn7ber)4 (grave number)
QName of SextonPer n i arge of Premises
Z (please print
w Signature �p�s CI-- Title 45
t
(over)
DOH-1555 (02/2004)