Shores, Alice 7# "fl
NEW YORK STATE DEPARTMENT OF HEALTH,Vital Records SectionBurial - Transit Permit
: •. Name First Middle Last Sex
• Alice M. Shores Female
Date of Death Age If Veteran of U.S. Armed Forces,
: August 14, 2016 51 War or Dates
14 Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause I ]Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
.r Charles Yun
:r Address
;1 102 Park Street,Glens Falls,NY 12801
:i::. Death Certificate Filed District Number Register Numb r
:*:: City, Town or Village Glens Falls 5601 `'J I
❑Burial Date Cemetery or Crematory
August 17, 2016 Pine View Crematory
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NI I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:;1 Permit Issued to Registration Number
.. Name of Funeral Home Regan Denny Stafford Funeral Home 01443
a`. Address
r 53 Quaker Road, Queensbury,NY 12804
t 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.
;:: .
Date Issued 21 16` j g Registrar of Vital Statistics
( gnature)
District Number 5601 Place Glens Falls;koly
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition g(/ff((, Place of Disposition ,Zit,,, C r,nc
W (address)
U)
O (section) / (lot number) S (grave number)
g Name of Sexton or Person in Charge of Premises ` nrt'''' ,i r
Z (pkase print)
W
Signature Title / ►14-
(over)
DOH-1555(02/2004)