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Ackley, Betty NEW YORK STATE DEPARTMENT OF HEALTH# , 4 193 Vital Records Section , Burial - Transit Permit Name First Middle Last Sex Betty A. Ackley Female Date of Death Age If Veteran of U.S. Armed Forces, March 31,2013 66 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death (x I Natural Cause Accident I I Homicide Suicide 1 i Undetermined Pending W 1 Circumstances Investigation t Medical Certifier Name Title Address Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 /3 7 ❑Burial Date Cemetery or Crematory April 4,2013 Pine View Crematory El Entombment Address ®Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address 1:: Hold to O Date Point of N Transportation Shipment a. by Common Destination Carrier Disinterment Date Cemetery Address Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 Address 3809 Main Street,Warrensburg,NY 12885 e Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ;X. Address 4 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 4 121&..3 Registrar of Vital Statistics C'3 CA t_.. ..kitiA. c J.l,ST- (signature) District Number 5601 Place Glens Falls /4/V /2 J©/ I certify that the remains of the decedent identified above were disposed !off in accordance with this permit on: w Date of Disposition y-S-13 Place of Disposition -?,�,� vi C tulrLv . (address) w cn ce (section) (lot number) (grave number) Q Name of Sexton or Person in Charge o Premises �r,>1 .. t v Z l (please print) W Signature i7 Title OttetN{ttic� (over) DOH-1555 (02/2004)