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Betz. John E Jr • If ,J NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John E.Betz Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 11/07/2023 86 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Kingsbury Town Street Address 3259 County Route 43 Route B,Kingsbury Town,New York 12827 W▪ Manner of Death ❑^ Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation LU Medical Certifier Name Title 0 David Foote MD Address 340A Main Street,Hudson Falls Village, New York 12839 Death Certificate Filed Town Of Kingsbury District Number Register Number City,Town or Village 5762 16 Burial Date Cemetery,Crematory or Facility Name 11/09/2023 Pine View Crematory Entombment — Address ©Cremation Queensbury Town,New York Donation OZ❑Removal Date Place Removed and/or and/or Held H Hold Address U) 0 d Date Point of U)❑Transportation Q by Common Shipment Carrier Destination oDisinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/08/2023 Registrar of Vital Statistics Cynthia ABardin(ECectronica1TySigned) (signature) District Number 5762 Place Town Of Kingsbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition i) 1i 173 Place of Disposition F Ai>aF0 (Pk,filttr liar... 2 (address) W U) CC (section) f(lot number) (grave number) SName of Sexton or Person in Charge of Premises A%)*_, So Mlj please print) W Signature Title (i/Nii lv c DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 1 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#