Bates, Alice it
NEW YORK STATE DEPARTMENT OF HEALTH * /3b
Vital Records Section , Burial - Transit Permit
Name First Middle Last Sex
Alice Terrisa Bates Female
Date of Death Age If Veteran of U.S. Armed Forces,
1 61 years War or Dates
� ��g�� beath Hospital, Institution or
Z CityTown or Village Street Addres
Sgchenectady His Hospital
M ❑Natural Cause ❑Accident ❑Homicide Suicide ri❑Undetermined El❑Pending
lu Circumstances Investigation
tu Medical Certifier Name Title
fl
AziEtzgantiiii M D
124 Rosa Rd Ste 382, Schenectady, N Y 12308
Iiiii Death Certificate Filed District Number Register Number
Cit to loge Schcncctady 4601 848
iMi❑Burial ate Cemetery or Crematory
<`['Entombment Ad1Jess)2016 Pine View Crematr'riurn
OCremation pucker Rd, Queensbu N Y
t ry,
Da a Place Removed
❑Removal and/or Held
and/or Address
i=` Hold
CA
0 Date Point of
Oi ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
itil Permit Issued to Registration Number
IIName of Funeral Home-Carleton Funeral Home Inc 00281
Address
68 M St, Box.67, Hudson Falls N Y 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IL
Permission is hereby granted to dispose of the human remai des bed ab a ads i icated.
10/05/2016
Date Issued Registrar of Vital Statistics t, t_F
.51 (signature)
iib District Number Place
4601 Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t Q 'I
tit Date of Disposition Apia,f( Place of Disposition fi'mutw 6 cj r...,
', (address)
to
U)
CC (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises A St"attr
2 ( ease paint)
• Signature a % Title (PEP4tP 4.
(over)
DOH-1555 (02/2004)