Bates, Christopher NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section _ s. Burial - Transit Permit
Name First I Middle Last Sex
Christopher David Bates Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 7, 2015 43 War or Dates
F— Place of Death Hospital, Institution or
Z W City, Town or Village Glens Falls Street Address 25 William Street
C1 Manner of Death a Natural Cause � Accident � Homicide Suicide Undetermined Pending
tL Circumstances Investigation
U
W Medical Certifier Name Title
0 Paul F Bachman MD,
Address
Warrensburg Health Center Warrensburg, NY 12885
Death Certificate Filed District Num��/ }�
Register >l�}rptlr
City, Town or Village
❑Burial Date Cemetery or Crematory
September 10, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
H Hold
Date Point of
ci. Li Transportation Shipment
Col_ by Common Destination
El' Carrier
Disinterment Date Cemetery Address
I Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
CC
IL Permission is hereby granted to dispose of the human remains describ b ve ind'
Date Issued ®�/O ?D/,5— Registrar of Vital Statistics ' � .
//
(signature)
District Number ,5 60/ Place �� y `/, NY
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 09/10/2015 Place of Disposition Quaker Road Queensbury,NY 12804
W (address)
0)
IX (section) �y (lot number) r (grave number)
Or
d; Name of Sexton or Perso in Cha a of Premises �!�t,, VAN
z' (pee-print)
W Signature Title ittiliillat
(over)
DOH-1555 (02/2004)