Gaston, Ana NEW YORK STATE DEPARTMENT OF HEALTH 11 gir-
t
Vital Records Section Burial - Transit Permit
Name Firs Middle st Sex
Ana Gaston Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/24/2013 60 years War or Dates
{ Place of Death Hospital, Institution or
g City, TX+ df•Xr MOW X Saratoga Springs Street Address Saratoga Hospital
Ui
0 Manner of Death Natural Cause ❑Accident ❑Homicide El Suicide El Undetermined ❑Pending
Ili Circumstances Investigation
Ca
ut Medical Certifier Name Title
Carlos A Ares Md
A S9 myrtle St, Saratoga Springs, N Y
Death Certificate Filed District Number Register Number
>' City, TUOPS004iXiji Saratoga Springs 4501 309
❑Burial Date Cemetery or Crematory
07/26/2013 Pineview Crematory
❑Entombment Address
(Cremation Schenectady, N Y
Date Place Removed
Z Removal and/or Held
fl❑and/or
Address
I:: Hold
O Date Point of
tii❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
• Address
z
III
` Permission is hereby granted to dispose of the human rem . sc ed alry indica d.
Date Issued 07/25/2013 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
1 -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILU Date of Disposition Place of Disposition
2 (address)
LEE
CC (section) (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises
2 (please print)
La
Signature Title
(over)
•
DOH-1555 (02/2004)