Adams, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ; - Burial - Transit Permit
Name Fir ary Middle LAdams Sex Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/04/2013 89 years War or Dates
le. Place of Death Hospital, Institution or
Z City, Tr id(M ( Saratoga Springs Street Address Mary's Haven
tkiManner of Death[3 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
Ul Circumstances Investigation
ill Medical Certifier Name Title
14 Rodney Ying MD
AdPi9 ss
myrtle Street Saratoga Springs, Ny
Death Certificate Filed District Number Register Number
City, T &XitAiiejeX Saratoga Springs 4501 326
•
OBurial Date Cemetery or Crematory
08/06/2013 Pine View Cemetery
0 Entombment Address
®Cremation Queensbury N Y
Date Place Removed
Z 0 Removal and/or Held
.... and/or Address
F" Hold
ft3
Q Date Point of
')El Transportation Shipment
. by Common Destination
Carrier
Disinterment Date Cemetery Address
.: Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc. 00364
Address
402 Maple Avenue, Saratoga Springs, N Y 12866
'� Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1
to
Permission is hereby granted to dispose of the human rem . scr ed above indicat d.
Date Issued 08/06/2013 Registrar of Vital Statistics
(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:
k �j }�
1 Date of Disposition g 11 I13 Place of Disposition 1 rntO(wo amit0c«u"`
2 (address)
ILI
1 (section) (lot n mber) (( (grave number)
Name of Sexton or Person - Charge of Pre ises ' ( S1" / Joorth
2 (ple se print)
l Signature Title �F�11Fria
(over)
DOH-1 555 (02/2004)