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Andrus, Viola NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit a Name First Middle Last Sex Viola Pearl Andrus Female Date of Death Age If Veteran of U.S. Armed Forces, w 12/28/2017 89 Years War or Dates F� Place of Death Hospital, Institution or Z City, Town or Village Albany Street Address Albany Medical Center Hospital 5 Manner of Death©Natural Cause 0 Accident ID Homicide El Suicide El Undetermined Pending W Circumstances Investigation Medical Certifier Name Title Lacey Raible NP Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed District Number Register Number City, Town or Village Albany 0101 2907 El Burial Date Cemetery or Crematory 01/02/2018 Pine View Crematorium El Entombment Address ;®Cremation Queensbury Town, New,,York Date riot Place Removed 2 Removal and/or Held 01-1 and/or Address Hold 0 Date Point of IL ❑Transportation Shipment 0 by Common Destination . Carrier 4❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address o, Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 ,, Address -" 68 Main Stpo Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom !. Remains are Shipped, If Other than Above Address LU tX--`, Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/29/2017 Registrar of Vital Statistics Daniel&sgi[fespie E(ectronicaaySigned (signature) District Number 0101 Place Albany, New York Yam I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1 Z o ,,pp w Date of Disposition f f ti ll Place of Disposition �/M� (r,,. ..r W (address) Cl) ed (section) number) SA.4 (grave number) pName of Sexton or Person i harge of Pr ises LLLLru Z (pleas print) Signature Title rvA 1 ���- (over) DOH-1555 (02/2004)