Kamburelis, Alice NEW PORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Alice Mae Kamburelis Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/18/2018 82 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death Natural Cause 0 Accident Q Homicide 0 Suicide riUndetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Philip Care MD
-� Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 3
❑BUrial Date Cemetery or Crematory
01/19/2018 Pine View Crematorium
❑Entombment Address `
(g]Cremation Queensbury Town, New York
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
0 El Transportation Shipment
by Common Destination
Carrier
,Q Disinterment Date Cemetery Address
h Q Renterment Date Cemetery Address
', Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
Fla 68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
.r Remains are Shipped, If Other than Above
I
Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/18/2018 Registrar of Vital Statistics Aimee 31afiioney(ECectmnica1T Signea
s (signature)
District Number 5755 Place Fort Edward, New York
X t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition I/21 lig Place of Disposition i,�uti,.� jr,,..�
a (address)
i (section) pJ (lot numbs (grave number)
Name of Sexton or Person in Charge of Pr mises it... •...,
z please print)
Signature Title !ho:m,* A
(over)
DOH-1555(02/2004)