Alden, Beverly 4.
NEW YORK STATE DEPARTMENT OF HEALTH t -41
Vital Records Section Burial - Transit Permit
` Name First Middle Last Sex
Beverly Jane Alden Female
Date of Death Age If Veteran of U.S. Armed Forces,
- January 14, 2013 80 War or Dates
i:
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Needle Park Circle Bldg 65 Apt 5
Manner of Death Undetermined Pending
❑X Natural Cause Accident � I Homicide n Suicide n
US Circumstances Investigation
uj Medical Certifier Name Title
a Glen Anderson,PA
Address
Queensbury,NY I OLt
Death Certificate Filed District Number Re i ter Number
City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
January 15, 2013 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road Queensbury, NY
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
Hold
N
Q Date Point of
❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
A 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
Remains are Shipped, If Other than Above
Address
US
Permission is hereby granted to dispose of the human re ains described a ove as indicated.
Date Issued l /IaCt3
1 [ 4C.Registrar of Vital Statistics --„_ A..c.,-....,
(signature)
District Number 5657 Place Queensbury,NY 11461
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Place of Disposition
2 (address)
W
N
rL (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises
Z (please print)
W
Signature Title
(over)
DOH-1555(02/2004)