Rice, Adele E NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Adele Elsie Rice female
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Date of Death Age If Veteran of U.S.Armed Forces,
9/1.8/90 81
War or Dates n o
Place of Death Hospital, Institution or
City,Town or Village City Glens Falls Street Address Glens Falls hospital
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G.:.:Manner of Death.............. :..:.:..............:::.:..:.:...:...:.:. Undetermined Pending
W x❑ Natural Cause ❑ Accident ❑Homicide ❑ Suicide
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Circumstances Investigation
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W Medical Certifier Name Title
p Thomas f . Kandora MD
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Address
7240 Broadway Fort Edward , NY 12828
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Death Certificate Filed District Number Register Number
City,Town or Village City Glens Falls 5601
Date Cemetery or Crematory
El Burial Sept 19 , 1990 Pine View Crematory
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ElCremation Address
Town of queensbury , NY
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Z Date Place Removed
0,, ❑ Removal and/or Held
F- and/or Hold ....................... . ...... ........: _ .... ............. .... ........ ..... ......... ..:.....
Address
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ILDate Point of
tn'' []Transportation by: Shipment
p; Common Carrier ............. .: . . _ .............::: : . ..... .. ..........................._ „::::,... _...,......... .__.. .....
Destination
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El Disinterment Date Cemetery Address
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❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Carleton Funeral Home , Inc . 00310
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Address
68 Main street Hudson Falls , NY 12839
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
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Address
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Permission is hereby granted to dispose of the human rem s described above as Indicated.
Date Issued 9/ 19/9 0 Registrar of Vital Statistics
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rDistrict NumberPlace `'
I certify that the remains of the decedent identified abdve were disposed of in accordance with this permit on:
W Date of Disposition/ /?—�O Place of Disposition / //�'4` ///�`
(address)
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N (section) (lot number) (grave number)
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p Name of Sexton Person i Charge of Prer es v�J
Z (Please print) Cilp /���Q�J`
w', Signature Title i
DOH-1555 (10/89) p. 1 of 2 VS-61