Shute, Alice It 4
NEW YORK STATE DEPARTMENT OF HEALTH Zg
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alice Shute Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/06/2014 79 years War or Dates
- Place of Death Hospital, Institution or
W City, MWRRKVARIARX Saratoga Springs Street Address Sarato a Hoc ital
• Manner of Death❑,Natural Cause ElAccident ElHomicide ElSuicide Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
n Rodney Ying MD
Address
59 Myrtle Street Saratoga Springs; Ny
Death Certificate Filed District Number 1 Register Number
City, ToWRXiXVk)XXX Saratoga Springs 4501 311
❑Burial Date Cemetery or Crematory
❑Entombment 07/07/2014 Pine View Crematory
Address
[jremation Queensburv, N Y
Date Place Removed
Z Removal and/or Held
91 ❑and/or Address
F Hold
f/x
0 Date Point of
CL
tin❑Transportation Shipment
by Common Destination
Carrier
ID Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave., Saratoga Springs, NY
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
W
fl" Permission is hereby granted to dispose of the human remai scrJed allow as indicated.
Date Issued 07/07/2014 Registrar of Vital Statistics , ,r„"Th 1- -4-ottiii-4
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z I Date of Disposition ) hi I lit Place of Disposition C;�
'naU:..., Ci - or s
2 (address)
LU
fil
CC (section) (lot number) (grave number)
0
• Name of Sexton or Person i Charge of Premises r
please print)
W
Signature 7i Title C
ar'vat
(over)
DOH-1555 (02/2004)