Pike, Carol NEW YORK STATE DEPARTMENT OF HEALTH # 713
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carol E Pike Female
tv
pi Date of Death Age if Veteran of U.S. Armed Forces,
Nu 12/11/2018 72 Years War or Dates
ril Place of Death Hospital, Institution or
a City, Town or Village Saratoga Springs Street Address Saratoga Hospital
rii Manner of Death 0 Natural Cause Ej Accident ED Homicide Ej Suicide ri Undetermined ri Pending
Circumstances investigation
Medical Certifier Name Title
Jennifer White DO
VI Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 652
m.
El Burial Date Cemetery or Crematory
12/13/2018 Pineview Crematory
❑Entombment
Address
®Cremation Queensbury Town, New York
Date Place Removed
Removal and/or Held
and/or
Hold Address
Date Point of
Q Transportation Shipment
g by Common Destination
re Carrier
• Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
ill Name of Funeral Home Densmore Funeral Home Inc 00448
• Address
piz 7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
;
• Permission is hereby granted to dispose of the human remains described above as indicated.
"1._ Date Issued 12/12/2018 Registrar of Vital Statistics John I'Tranck(ECectronicaffySigned)
(signature)
District Number 4501 Place Saratoga Springs, New York
l
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 2 S Place of Disposition
- p i �i9 I� p ���J ���v1•.,;.�
(address)
(section) not number) C (grave number)
]Name of Sexton or Person in Charge of Premises Ori ki � ��^tit
�
(pleas print)
• Signature �� 4. Title itzFe k1L
(over)
DOH-1555 (02/2004)
i.