DeJesus, Josiah NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit#u�
Vital Records Section
Name First Middle Last Sex
JOSIAH DEJESUS FETAL
Date of Death Age If Veteran of U.S.Armed Forces,
03/04/2020 FETAL War or Dates
Place of Death Hospital, Institution
City ,Town or Village City of Albany or Street Address ALBA MEDICAL CENTER
Manner of Death Natural Accident Homicide ❑ ndetermined ❑ Pending
❑ ❑ ❑ ❑ Suicide
W (FETAL) Cause Circumstances Investigation
Medical Certifier Name Title
� RACHEL FLINK-BOCHACKI MD
Address
43 NEW SCOTLAND AVE ALBANY NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village City of Albany 101 FETAL
Date �PPINEVIEW
emetery or Crematory
❑ Burial 03/09/2020 CREMATORti
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
F- Hold
Date asp
Carrieroint of
aTransportation hipment
N ❑ By Common
p Destination
❑ Disinterment Date Cemetery Address
❑ Renterment Date Cemetery Address
Permit Issued To Registration Number
Name of Funeral Home BAKER FUNERAL HOME 01130
Address
11 Lafayette Street, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
f- Remains are Shipped, If Other than Above
Address
dPermission is hereby granted to dispose of the human remains describe above as in ated.
Date 03/09/2020
Issued Registrar of Vital Statistics
(signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
n:
Z Date of Disposition 311 I Lb Place of Disposition �1' L 110l
LU (address)
W
(section) of number) (grave number)
O
WName of Sexton or Person in Charge of Premises r•) L- IT-
please print)
Signature 14, Z Title
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) J 13 41
Receipt
Human remains of _ delivered on , 20_
t
%Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# t