Adam, Eva NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eva K Adam F
Date of Death Age If Veteran of U.S. Armed Forces,
1 2/2 9 6 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
JIM J MIchael O'Connell MD
Address
42 Myrtle St Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or VillageSaratoga Springs r/
Date Cemetery or Crematory
El Burial 12/24/96 Pineview NXNXX XyX Crematory
Address
OCremation Quaker Rd Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
•- and/or Address
Hold
Q Date Point of
N❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to 70,1937
istration Number
Name of Funeral Home Tunison F/H
Address
105 Lake ADe Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Z.
Permission is hereby granted to dispose of the human mai s scribed a ve indicated.
Date Issued /z- 194 Registrar of Vital Statistics
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition
(address)
LU
>E (section) (lot number)- (grave number)
GName of Sexton or Person in Charge of emises .�,j Zr��0 AIP T J
z (please print) f
W Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61