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Gray, Ada NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Sex Name First Middle -7 Last Ada A. Gray F Date of Death Age If Veteran of U.S. Armed Forces, 08-05-97 83 War or Dates NA Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address 150 Ridge St. Manner of Death x❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title G. Abess MD Address Glens Falls, NY Death Certificate Filed District Number Register Number <`' City, Town or Village Glens Falls 5601 3 Date Cemetery or Crematory ❑Burial 08-06-97 Pine View Crematory ©Cremation Address Queensbury, NY Date Place Removed Z❑Removal and/or Held ... and/or Address }" Hold E� Q Date Point of N❑Transportation Shipment fl by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Adirondack Cremation Associates Registration Number Name of Funeral Home 02168 Address Warrensburg, NY Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as ind' ed. Date Issued 8-6-97 Registrar of Vital Statistics z'� � (signature) District Number 5601 Place City of Glens Falls,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: z Date of Disposition-�9/ Place of Disposition �!/�� �//��� �' / /O�/if UJ (address) LIJ (section)r (lot number) (grave number) � 0 Name of Sext or Person in Charge of Premises wGcl 'rf � (please print) i 101 Signature Title DOH-1555 (10/89) p. 1 of 2 VS-61