Fowler, Betty .j tiSZl
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Betty Mae Fowler Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 31 , 2013 92 yrs. War or Dates none
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
114
ci Manner of Death uicNatural Cause ril Accident 0 Homicide D Suicide ElUndetermined ri❑Pending
Circumstances Investigation
W Medical Certifier Name Title
44. Jennifer Stratton, MD.
Address
14 Manor Drive, Queensbury, NY. 12804
Death Certificate Filed District Number Register Number
>i.
< City, Town or Village Glens Falls 5601 '3 -76
❑Burial Date Cemetery or Crematory
❑Entombment Address 03, 2013 PineView Crematorium
;;aCremation Queensbury, NY. 12804
Date Place Removed
Removal and/or Held
9and/or Address
= Hold
{t/
Date Point of
ei0 Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01 11 7
Address
18 George St. , Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
M.
I
CL
Permission is hereby granted to dispose of the human remains des ribed
above a /dicated.
IN Date Issued 0 9/0 3/1 3 Registrar of Vital Statistics /�� w•r
(signature)
District Number 5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z. l�
ill Date of Disposition 4 j31a Place of Disposition P..4.Vn�J acfcc,....
a (address)
Lu
til
CC (section) (lot number) (grave number)
el Name of Sexton or Person in harge of: remises Ai4it /4-11
(phase..print)
10
Signature Title Cgttt 'tVi
(over)
DOH-1555 (02/2004)