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Patten, Alberta . . t # 7// NEW YORK STATE DEPARTMENT OF HEALTH � Vital Records Section Burial - Transit Permit Name First Middle Last Sex Alberta Irene Patten Female Date of Death Age If Veteran of U.S. Armed Forces, 09/24/2017 94 Years War or Dates Place of Death Hospital, Institution or WCity, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc a Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending 111 Circumstances Investigation ui Medical Certifier Name Title d Thomas Kandora MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City, Town or Village Fort Edward 5755 43 ❑Burial Date Cemetery or Crematory 09/26/2017 Pine View Crematorium ❑Entombment -°� Address ®Cremation Queensbury Town, New York Date Place Removed Removal and/or Held 2 and/or Address Hold ✓ Date Point of • Transportation Shipment O by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number • Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Stpo Box 67,Hudson Falls,New York 12839 :z Name of Funeral Firm Making Disposition or to Whom l Remains are Shipped, If Other than Above _ • Address IZ d Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/26/2017 Registrar of Vital Statistics Aimeeivahoney 'EfectronicalrySigned (signature) District Number 5755 Place Fort Edward, New York ..:' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: l Date of Disposition q i II/0piece of Disposition -RI UN,./ O (address) W re (section) (lot number) (grave number) Z Name of Sexton or Person in Charge of Pre ises 4&4cfr&&_ �ak4tbf �� (pprint) W. Signature G4 Title (pcMvia 9 (over) DOH-1555 (02/2004)