Gage, Patricia t '►
A q T1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patricia Jane Gage Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/18/2017 72 Years War or Dates
▪ Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause ❑Accident El Homicide El Suicide ❑Undetermined ❑Pending
wW Circumstances Investigation
Medical Certifier Name Title
Sean Bain MD
45,, Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 595
❑Burial Date Cemetery or Crematory
11/20/2017 Pine View Crematorium
bl❑Entombment Address
; ;' ®Cremation Queensbury Town, New York
Date Place Removed
t,ni Removal and/or Held
and/or Hold Address
LiQ
P Date Point of
Q TransportationCO Shipment
by Common Destination
Carrier _
s Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
', Name of Funeral Home Carleton Funeral Home Inc 00281
4 Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
III Remains are Shipped, If Other than Above
• Address
OC
LLI%- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/20/2017 Registrar of Vital Statistics Wp6ertA Curtis TCectronicallySigned"
(signature)
-, District Number 5601 Place Glens Falls, New York
HI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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v fi
• Date of Disposition �1�Z2�l1 Place of Disposition I� „� � ...-
2 (address)
lioi
In
te.
(section) 4(lot number),. (grave number)
aName of Sexton or Person in Charge of Premis ILA? . t-vviO'
! (plOase print)
▪ Signature 4 Title tr&I"efje-
(over)
DOH-1555 (02/2004)