Towne, Beverly NEW YORK STATE DEPARTMENT OF HEALTH ' f .. 317
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Beverly Jane Towne Female
Date of Death77 Age If Veteran of U.S. Armed Forces,
l* e o1Dea 1h2 74 years War or Dates
6O ,Jf
spitanstitution or
City, o Street Address
o eat V atural Cause-
Accident El Homicide El Suicide n e ermine ending
iti
(. Circumstances Investigation
iii Medical Certifier Name Title
0
Add eosscrt W. Sponzo M. D.
102 Park Street Glens Falls, Ny 12801
1 •- Certificate Filed District Number Register Number
i "beitxvatigtxx Glens Falls 5601 321 •
ffi 11 Burial Cemetery or Crematory
;;pEntombment 07/09/2012 Pine View Crematory
1>
Address
114remation Queensbury, NY •
Date Place Removed
❑Removal and/or Held
and/or Address
i=` Hold
CA
0 Date Point of
tlit$ El Transportation Shipment
G by Common Destination •
Carrier
ID Disinterment Date Cemetery Address
u,iiEl Reinterment Date Cemetery Address
tii •
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
tr
to •
CL
Permission is hereby granted to dispose of the human remains descri ed abov s i�Q�c ted.
Date issued 2 Registrar of Vitai Statistics 07/O�i/ 01
(signature) •
District Number 5601 Place (;lens Fai s
I cI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
at Date of Disposition 1-to-it Place of Disposition 9r..1.1)tps. Crrtnr,fvrah.
(address)
ILI
CO
CC (section) A . (lot number) ( (grave number)
ci Name of Sexton or.P son in Charg of Premises t nris r JCkilf
(please print)
g
Si nature L�'► Title (t 4'11'MIL
(over)
DOH-1555 (02/2004)