LaBounty, Beverly NEW YORK STATE DEPARTMENT OF HEALTH ' 11
Vital Records Section 1.1 Burial - Transit Permit
Name First Middle Last Sex
Beverly R. LaBounty Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 22,2013 73 War or Dates
Place of Death Hospital, Institution or
• City, Town or Village Chester Street Address 8 Bird Pond Road
pManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
ill Medical Certifier Name Title
a William Connor PA
Address
North Creek Health Center,North Creek,NY 12853
Death Certificate Filed District Number Registerrmber
City, Town or Village Chester 5652
❑Burial Date Cemetery or Crematory
March 25,2013 Pine View Crematory
Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NI !Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment 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
Ib. Remains are Shipped, If Other than Above
Address
LL9'
a Permission is hereby granted to dispose of the human re ain descri e a ve'as i dicatedf
3 Date Issued /�6 /3 Registrar of Vital Statistics J�� � ! i '
f
(signat e)
District Number 5652 Place Chester
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3-21-13 Place of Disposition Rea U
W (address)
co
ce
(section) (lot numb (grave number)
pName of Sexton or Person in Charge of remisest�n '
Z (please print)
W Title CIZt 1w'i�
Signature 4131—
(over)
DOH-1555 (02/2004)