Pike, Ronald NEW YORK STATE DEPARTMENT OF HEALTH f Burial _ Transit Permit
Vital Records Section
' s Name First Middle Last Sex
Ronald Robert Pike Female
a Date of Death Age If Veteran of U.S. Armed Forces,
�E December 12, 2014 65 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 25 King Ave
Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
`, Joseph Foote MD,
at Address
Rt 4 Hudson Falls, NY 12839
D• eath Certificate Filed District Number Register Number
i'4 C• ity, Town or Village c 7 6 a 3
': ❑Burial Date Cemetery or Crematory
December 17, 2014 Pine View Crematorium
, ❑Entombment Address
:®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
o and/or Address
Hold
Date Point of
❑Transportation Shipment
. by Common Destination
la Carrier
kI
ElDisinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
)!'• ', Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
s' 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
' 'b-, Remains are Shipped, If Other than Above
2 Address
LU
4', Permission is hereby granted to dispose of the human remains described above as indicated.
�9�cu a Date Issued i� /S" j/y Registrar of Vital Statistics G . ,
(signature)
District Number S 7;6 Place (/ �
G-t'
5I ;• ; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ujDate of Disposition 12/17/2014 Place of Disposition Quaker Road Queensbury,NY 12804
i (address)
U
(section) (lot number) (grave number)
'16, dr
Name of Sexton or Pers in Charge f Premises r. 4- i or L'
�; (ease print)
LU, Signature Title t .
(over)
DOH-1555 (02/2004)