Carey, Patricia NEW YORK STATE DEPARTMENT OF HEALTH, ' I40
Vital Records Section Burial - Transit Permit
=➢"; Name First Middle Last Sex
p ° Patricia A. Carey Female
.gip= Date of Death Age If Veteran of U.S. Armed Forces,
:!: February 10,2016 73 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Bolton Street Address 4934 Lake Shore Drive
Q Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
, Circumstances Investigation
Medical Certifier Name Title
`a° William Orluk Coroner
Address
f=g Chester Health Center,Chestertown,NY 12817
Death Certificate Filed District Number Registe,�Number
c; City, Town or Village T/O Bolton 5650
❑Burial Date Cemetery or Crematory
February 12,2016 Pine View Crematory
El Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804 _
Date Place Removed
ZO Ti Removal and/or Held
and/or Address
H Hold
U)
0 _ Date Point of
O.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:_J Permit Issued to Registration Number
o<= Name of Funeral Home Alexander-Baker Funeral Home 00037
; Address
a; 3809 Main Street,Warrensburg,NY 12885
._ Name of Funeral Firm Making Disposition or to Whom
tIRemains are Shipped, If Other than Above
Address
s Permission is hereby ranted to dispose of the human re ain described a v as Ind' ated.
_1 Date Issued 4/////41 Registrar of Vital Statistics Z U (f�
�S i _
District Number 5650 Place T/O Bolton,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
utDate of Disposition 2 f n,J/( Place of Disposition 1?ni 0 014 Lr rn4a luL.
W (address)
U)
QCC (section) atis<iflotitin.sumbeeopott (grave number)
Name of Sexton or Person in Charge of Premises
Z ease print)
W /j
(
Signature L[ _214ir Title (VAC A1690
(over)
DOH-1555 (02/2004)