Quallo, Jacqueline NEW YORK STATE DEPARTMENT OF HEALTH .i 1C)
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jacqueline Quallo Female
>`_ Date of Death Age If Veteran of U.S. Armed Forces,
02 / 11 / 2018 •87 War or Dates N/A
Place of Death Hospital, Institution or
City, Town or Village Albany, NY Street Address Albany Medical Center
LLI
g Manner of Death®Natural Cause 0 Accident 0 Homicide El Suicide 0 Undetermined �Pending
111 Circumstances Investigation
tu Medical Certifier Name Title
ct. Sherif M Shoucri MD
Address
47 New Scotland Ave Albany, New York 12208-3412
Death Certificate Filed District Number Register Number
City,Town or Village Albany, NY O3.5.t
El Burial Date Cemetery or Crematory
02 / 13 / 2018 Pine View Crematory
gi 0 Entombment Address
Oi ECremation Queensbury, NY
Date Place Removed
X g 7❑Removal and/or Held
and/or Address
0
Hold
Date Point of
Transportation Shipment
is by Common Destination
Carrier
ilkii
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave., Saratoga Sp. , NY 12866
im Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
5
Permission is hereby granted to dispose of the human remains d scribed above as indicated.
• Date Issued b 2./I y/1 Registrar of Vital Statistics /�� ,(4"
(sign re)
District Number 01 O I Place Albany, NY , New York
# I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition?f t S11os&' Place of Disposition fitted Vi c,i,) G ist/4 44Gr '
(address)
LU
IC (section) (lot number) (grave number)
CIName of Sexton or Person ill Charge of Premises -am-c.y Stu It-S
Z j • s (please print) •
114
Signatures -'�"i Title Gf c.✓h(4 4'c.r
(over)
DOH-1555 (02/2004)