Ames, Theodore I/3°c
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
t- Name First Middle Last Sex
Theodore William Ames Male
Date of Death Age If Veteran of U.S. Armed Forces,
at April 11, 2018 57 War or Dates
14: Place of Death Hospital, Institution or
City, Town or Village Kingsbury Street Address 109 Queens Drive
Manner of Death ❑Natural Cause ❑ Accident ❑ Homicide X❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
O Michael Sikirica MD,
Address
. 50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
4 City, Town or Village 3 7 6 a)- 3
Date Cemetery or Crematory
. . ❑Burial April 16, 2018 Pine View Cemetery
❑Entombment Address
WTI
fti®Cremation
Date `.
Z El
Removal
and/or Address
Hold
Date of
�'0 Transportation ?ment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
eName of Funeral Home Carleton Fun ari Home, Inc. 00281
444 Address
M. Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
j Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
,Z= Address
w'
� P• ermission is hereby granted to dispose of the human remains described above as indicated.
D• ate Issued Yi /1 Registrar of Vital Statistics e r t-t- LA 4 / .i.'i
(signature)
District Number /
S�G,X Place �i�wh �i � �,-tis t Ei�; ry
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tkift Date of Disposition 04/16/2018 Place of Disposition {;,,J.,. t .,16 r-
(address)
A
I (section) 4 (lot number)(` (grave number)
Name of Sexton or Person in Charge of Premises . J i--
d ( ease print)
Signature /Zip, Title (MAI i -
(over)
DOH-1555 (02/2004)