Gates, Mary 10/12/2015 07:04 5183773446 T • f LIGHTS FUNERAL HOME PAGE 01/01
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
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": Name First Middle Last Sex
MARY E. GATES _FEMALE
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Date of Death • - Age' If Veteran of U.S. Armed Forces,
1' 10/8/2015 71 War or Dates -
Place of Death Hospital, Institution or
City, Town or Village ALBANY Street Address ALBANY MEDICAL CENTER
_
Manner of Death El Natural Cause E]Accident Ca Homicide 0 Suicide Undetermined Pending
na, Circumstances Investigation
Medical Certifier Name u Title .
.,m: MUHAMMAD MORAL MD
•'. ,- Address
,,,
AMCH 43 NEW SCOTLAND AVE ALBANY, NY 12208
z"• Death Certificate Filed District Number Register Number •
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' City,Town or Village ALBANY 101
''"" Date Cemetery or Crematory
' ■• Burial 10/13/2015 ;PINE VIEW CREMATORY _
L Enfarnbrrnent
Address
, OCremation QUEENSBURY, NY. '
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' Date Place Removed
.�•-n Removal and/or Held 'el _
and/or Address
Hold
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Date Point of
;A ❑Transportation Shipment
i,r, by Common Destination
,,,. Carrier
• Disinterment Da#e Cemetery Address
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r'`11 Reinterment Date Cemetery Address
Permit Issued to Registration Number
=z Name of Funeral Horne
SINGLETON SULLIVAN POTTER FUNERAL HOEff1596
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Address 407 BAY ROAD QUEENSBURY, NY 12804
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ei Name of Funeral Firm Making Disposition or to Whom ~'
ERemains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
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;.? Date Issued 10/11/2015 Registrar of Vital Statist -.e__ t7 484
(signature)
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District Number 101 Place ALBANY POLICE DEPT. y
I certify that the remains of'the decedent identified above were disposed of in accordance with this permit on;
Date of Disposition . Io/9/15' Place of Disposition AIL or+w- '
,6 s (address)
(section) trot Itun7ber (grurve number)
. Name of Sexton or Person in Charge of Premises tI -aye tw+ 4
TA►Q print)
44 Signaturerif _ Title (0409IL
(over)