Byrne, Nolakwo
NEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Burial - Transit Permit
Name First Middle Last
Sex
Nola Mae Byrne
I Female
Date of Death
Age
If Veteran of U.S. Armed Forces,
10/20/2019
37 Years
War or Dates
E..
Place of Death
--JStreet
Hospital, Institution or
W
City, Town or Village Albany
Address Albany Medical Center Hospital
p
Manner of Death Natural Cause Accident Homicide Suicide ❑ Undetermined Pending
U
Circumstances Investigation
W
Medical Certifier Name Title
0
Abdul Khan
Address
43 New Scotland Ave, Albany, New York 12208
Death Certificate Filed
District Number
Register Number
City, Town or Village Albany
0101
2254
Burial
Date Cemetery, Crematory or Facility Name
Entombment
10/25/2019 Pine View Crematory
Address
RCremation
Queensbury Town, New York
Donation
Removal
Date
Place Removed
z
and/or
and/or Held
Hold Address
G.
Date Point of
to
G
❑ Transportation Shipment
by Common
Carrier
Destination
Disinterment
Date
Cemetery Address
Reinterment
Date
Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home Maynard D Baker Funeral Home
01130
Address
11 Lafayette St, Queensbury, New York 12804
Name of Funeral Firm Making Disposition orto Whom
Remains are Shipped, If Otherthan Above
2
Address
Im
U,1
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/22/2019 Registrar of Vital Statistics rDami?&Sgffespre�--&-tmmcalySign,4
(signature)
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:
ZZ
Date of Disposition 10 %ZS j lq Place of Disposition !
UJI
2
(address)
W
N
(section) l/ot number) (grave number)
Name of Sexton or Person in Charge of Premises t" L In.�l1
(p! se print)
W
Signature Title
DOH-1555 (07/18) p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of
Pine View Cemetery
Official
delivered on , 20 `
Representing the funeral home named on burial permit
Funeral Director-
,.,Jkeg. or License #