Belden, Betty NEW YORK STATE DEPARTMENT OF HEALTH �3
Vital Records Section , N Burial - Transit Permit
x• 'e'° Name First Middle Last Sex
Betty Ann Belden Female
Date of Death Age If Veteran of U.S. Armed Forces,
, January 5,2013 58 War or Dates
i Place of Death Hospital, Institutiorsxtlie Stanton Nursing& Rehabilitation
tii City, Town or Village Queensbury Street Address Centre
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
VI Circumstances Investigation
,to Medical Certifier Name Tit
, , Roslyn Socolof MD
Address174 Sherman Avenue, Queensbury, NY 12804
' Death Certificate Filed District Number Register Number
;�:1 City, Town or Village Queensbury 5657 d
❑Burial Date Cemetery or Crematory
January 10,2013 Pine View Crematory
El Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
• Permit Issued to Registration Number
• 1 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
tow Remains are Shipped, If Other than Above
2] Address
It
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Ai lac).! Registrar of Vital StatisticsZj 4� CI, /l,�'�.
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition I-Id-t Place of Disposition �sd6u., C�a1++'�rrw...
W (address)
U)
✓ (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises ri0 ,5i,4f
Z �f (please print)
W Signature Gto�(ri� Title C12eP1i1-to L.
1 (over)
DOH-1555 (02/2004)