Adams, Carole r
170
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carole L. AdamS Female
Date of Death Age If Veteran of U.S. Armed Forces,
02 / 27 / 2017 54 War or Dates N/A
Place of Death Hospital, Institution or
ZCity, Town or Village Saratoga Springs Street Address Saratoga Hospital
0 Manner of Death i Natural Cause 0 Accident E Homicide —Suicide n Undetermined 0 Pending
la
Circumstances Investigation
{j j Medical Certifier Name Title
0 Rodney L. Ying MD
Address
59 Myrtle St # 300, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 2150) 1 I3
EBurial Date Cemetery or Crematory -+
02 / 28 / 2017 1 Pine View Crematory
ElEntombment Address
P:1 ECremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
Q❑and/or Address
E Hold
Ca
0 Date Point of
Si0 Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
,r
Reinterment Date Cemetery Address
>: Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
f<> Address
402 Maple Ave., Saratoga Sp. , NY 12866
Name of Funeral Firm Making Disposition or to Whom
i4 Remains are Shipped, If Other than Above
Address
fr
Ili
". Permission is hereby granted to dispose of the human remains ' e boyar ' 'cated.
Date Issued o�, i
(-3" Registrar of Vital Statistics
(signature)
District Number 1-15D' Place Saratoga Springs , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 3 /-/7 Place of Disposition ?YlQL); et...)e_ce ii1e,• ir2/0-
(addreIs)
at
to
CC (section) , J (lot number) (grave number)
QName of Sexton or o 'ip Charge of Premises J G.l ) ri C a4--A e-
z > (please print) •
f Signature t-el ^v Title C( 4�" -
(over)
DOH-1555 (02/2004)