Fetal, VanVlack, Joseph 12/18/2019 11:24 5183773446 LIGHTS FUNERAL HOME PAGE 01/01
NIWV YORK STATE DEPARTMENT OF HEALTH Burial
vital Records Section 4�
Name First --�` — Midd Tra
■ i pprrk�l
FETAL cose ►� 1�qh . .
Date of Death �� - Sex
12/12/2019 Age If Veteran of U.S.Armed Forces, FETAL
Place of Death FETAL
War or Dates
` City,Town or Village Cif of Alban Hospital, Institution
Manner
of Death o Natural or Street Address AMC
FETAL
Cause ❑ Accident ❑ Homicide Undetermined
Medical Certifier Name ❑: Suicide Pending
RACHEL FUNK-BOCHACICI Circumstances investigation
1 Title
Address IVILI
43 NEW SCOTLAND AVE, AI l3ANY NY 12208
Death Certificate Filed
Cry,Town or Village District Number Ct# of Alban Register!Number
ry
Date 101 FETAL
0 Burial 12/18/2019 Cemetery or Cremato
❑Entombment PINE VIEW
0 Cremation Address
"{- 21 QUAKER RID, QUEENSBURY
Date , NY 12804
C), ❑ Removal Place Removed
,� and/or Address and/or Weld
Hold .
Date
Transportation" Point of
❑ By Common Shipment
Carrier Destination
❑ Disinterment Date Cemetery Address
❑ Renterment bate Cemetery Address
Permit Issued To
' Name of Funeral Home REGAN DENNY STAFFORD FUNERAL HOME Address Registration Number
1403
490 DELAWARE AVE, ALBANY NY 12209
Name of Funeral Firm Making bisposition or to Whom '
Remains are Shipped, If Other than Above
Add14 ress
";;A Date
is hereby granted to dispose of the human remains described above as indicated.
Date 12/18/20'19 -
Issued Registrar of Vital Statistics
(signatu
Distrid Number 101 Place Cfty of Alban , NY
Y
I certfr that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition (Z Irr IDS Place of Disposition _. You d,., (p"-+a few
ur (address)
D. (section) (lot num 0 (grave number)
ZName of Sexton or Person in Charge of premises
(please print) d/�
Signature (/•-/ Title r,011TVA
(over)
DOH-1555(0212004)
i
Public Health Law Sec. 4145(2b) - _
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#