Rathbun, Alyce M 4;1
NEW YORK STATE DEPARTMENT OF HEALTH 27
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Alyce M.Rathbun Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/27/2022 96 Years War or Dates
i,— Place of Death Hospital,Institution or
WCity,Town or Village Fort Ann Town Street Address 1702 County Route 16, Fort Ann Town,New York 12827
O Manner of Death 0 Natural Cause Accident 0 Homicide Suicide Undetermined ❑Pending
U' Circumstances Investigation
Li„ Medical Certifier Name Title
G1 John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Fort Ann District Number Register Number
City,Town or Village 1 5754 8
Burial Date Cemetery,Crematory or Facility Name
03/29/2022 Pineview Crematory
Entombment Address
JCremation Queensbury Town,New York
❑Donation
Z' I Date Place Removed
0 U Removal
and/or and/or Held
a. Hold Address
0
A, Date Point of
W❑Transportation
by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment
E Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
XAddress
tr
tun Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/28/2022 Registrar of Vital Statistics Barbara J Winchell(Electronically Signed)
(signature)
District Number 5754 Place Town Of Fort Ann
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tDate of Disposition j11a 112. Place of Disposition ,e4744q` 4(t.6-.-
IU
2 (address)
W'
C (section) / (lot number/ (grave number)
Li Name of Sexton or Person in Charge of Premises Ali rw 1++ t 11�
/pase print/
ill Signature a ,�G� Title 04MYIrvt's.
DOH-1555(07/18)p 1 of 2
F.t',4{ "
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home namedpj}burial permit
Official Funeral Directors Reg.or License#