Sabota, Theresa -7-7 -7
NEWYORK STATE DEPARTMENT OFHEALTFY ., Burial
- Transit Permit
Bureau of Vital Records '
Name First Ale Last Sex
Theresa D.Sabota Female
Date of Death Age ran of U.S.Armed Forces,
11/22/2019 68 Years or Dates
Place of Death Hospital,Institution or
W City,Town or Village Albany Street Address St Peters Hospital
p Manner of Death ®Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
C1 Korey Marshall NP
Address
315 S Manning Blvd,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 2511
Burial Date Cemetery,Crematory or Facility Name
11/2512019 Pine View Crematory
Entombment Address
®Cremation Queensbury Town,New York
11 Donation
Date Place Removed
Removal and/or and/or Held
�
us
Address
dDate Point of
N Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/22/2019 Registrar of Vital Statistics (Danielle S GJesTw(Electronically SWn4
(signaturel
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
W Date of Disposition 111 tsl y� Place of Disposition (address%vt"
2
W
U) (section) (lot number) (grave number)
O Name of Sexton or Person in Cha a of Premise r•►
Q (Plilbse printj
z to
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013 �
Receipt
Human remains of '� ~.�'` "'~ delivered on ,�= 20'
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#