Shields, Arlys Sop
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Arlys Rae Shields Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 8,2013 73 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Saratoga Springs Street Address Saratoga Hospital & Nursing Home
Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
C)
W Medical Certifier Name Title
G Rachid Daoui Dr.
Address
6 Care Lane,Saratoga Springs,NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga 4501
❑Burial Date Cemetery or Crematory
ID Entombment September 12,2013 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZO I I Removal I and/or Held
and/or Address
F Hold
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
II Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address --- --- --- -
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
W
O.
Permission is h re y granted to dispose of the human rem . scrybed.alp s Indic ed.
Date Issued Registrar of Vital Statistics ¢'�w� 1I
(signature)
District Number 4501 Place Saratoga
iL I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu Date of Disposition `�(t3I13 Place of Disposition Li tOt,r.►
(address)
f�
(section) (lot numb (grave number)
ZName of Sexton or Person in harge of Pr ises .r, , pw4
Z please print)
Signature Title
(over)
DOH-1555 (02/2004)