Benson, Betsy A BENSON
NAME q":"F) Age:
Betsy A Benson 76
Lot OwnRbbert Benson
Lot# Horicon 45 D Grave# 2
Case: Concrete
Died: 6.8.2 3 Interred: 6.1 4 .2 3
Funeral Home: Regan Denny Stafford
Cemetery: Pine View
NtW YUKKSIAIL UtPAKIMhN I OF HtALIH Bureau of Vital Records1-1(.....5Burial Transit Permit
Name First Middle Last Sex
Betsy A Benson Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/08/2023 76 Years War or Dates
H Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death El Natural Cause Accident E Homicide nSuicide FlUndetermined ri Pending
W
V Circumstances Investigation
W Medical Certifier Name Title
0 Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 294
Burial Date Cemetery,Crematory or Facility Name
06/14/2023 Pine View Cemetery
Entombment Address
Cremation Queensbury Town,New York
nDonation
8nRemoval Date Place Removed
and/or and/or Held
t- Hold Address
N
0
0. Date Point of
CO nTransportation Shipment
p by Common
Carrier Destination
riDisinterment
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 Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
i.. Remains are Shipped,If Other than Above
2 Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/12/2023 Registrar of Vital Statistics Megan Nofin(Efectronica1CySigned)
(signature/
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
W Date of Disposition L0_fi Lk.a Place of Disposition Q` ib, Loy,cv r j� J� u cj N / �
(a dress/
Q (section) (lot number)�® \— (grave number)
0 Name of Sexton or Person in Charge of Premises >�Yli e � um`��-�-T
C Z (please print)
W Signature Title a_IVE'J(-'►51 )X--Nc e_il1A—
DOH-1555(o7h8)p 1 of 2
Public Health Law Sec. 4145(2b)
t1983
Receipt
Human remains of delivered on , 20_
Pine View Cem tery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
BENSON
Owner C.)
Robert Benson
Address Plot
2754 Rte. 9 Lake George NY 17R45 Horicon
Phone # Let #
518-6682492 45 D
Deed # Date
4389 6.9.23
Cost Foundation Y - N
$1 600.00
Location West-Rowe/Lunt
South-Vacant
North-Baldwin
East-Vacant
Remarks
I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE
PINE VIEW CEMETERY:
SIGNATURE: DATE:
SIGNATURE: 1P , DATE: �/9�G'323
Record of Interments
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3 8
4 9
5 10
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