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Bates, Edwin NEW YORK STATE DEPARTMENT OF HEALTH ' 4/1 22- Vital Records Section Burial - Transit Permit Name First Middle Last Sex Edwin Orlie Bates " ' Male Date of Death Age If Veteran of U.S. Armed Forces, February 4, 2017 62 War or Dates IE Place of Death Hospital, Institution or 1JJ City, Town or Village Glens Falls Street Address Glens Falls Hospital O Manner of Death X❑ Natural Cause 0 Accident ❑ Homicide I I Suicide ❑ Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title 0 Lynn Keil, Address HHHN West Mountian Queensbury, NY 12804 Death Certificate Filed District Number pp Register Number City, Town or Village 5 C� o f 23 ❑ Burial Date Cemetery or Crematory February 13, 2017 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ElRemoval and/or Held 0and/or Address Hold Pine View Crematorium CO Date Point of fa. ri Transportation Shipment CO by Common Destination CI Carrier Disinterment Date Cemetery Address nReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above M Address Ui Ct. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued ?/ '7 i 2c i 7 Registrar of Vital Statistics C-kA ry-.Q (signature) District Number 5-6-CI Place 6 S V \\5 t v `1 • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 02/W2017 Place of Disposition Quaker Road Queensbury,NY 12804 i1y,,2. M (address) W f17' Ce (section) (lot number) (grave number) aName of Sexton •' ' incharge of Premises �fr-'l is 4 a.,04 rc.e, Y Z (please print) W Signature � ' �.i .e------'".. Title �-'ro--r✓k Zec7 Oil c?��kc� (over) DOH-1555 (02/2004)