Columbetti, Betty NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Betty Jean Columbetti Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 21, 2013 87 War or Dates
1.- Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address 15 Second Street
in• Manner of Death x Natural Cause n Accident Homicide n Suicide n Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
• Jennifer Stratton MD
Address
14 Manor Drive,Queensbury NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 1439
❑Burial Date Cemetery or Crematory
November 22, 2013 Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n 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 Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ) 121 /12 Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W• Date of Disposition Place of Disposition gutkilsL,/ 1
(address)
N
(section) /� (lo number) r (grave number)
Name of Sexton or Person in Charge of Pr mises
Z ( se print)
W I (.,_Signature
Title Ct1 "1t1
(over)
DOH-1555(02/2004)