Barber, Fetal NEW YORK STATE DEPARTMENT OF HEALTH s • Burial - Transit Permit i5C
Vital Records Section
Name First Middle Last Sex
4,1 FETAL FETAL BARBER FETAL
• Date of Death Age If Veteran of U.S.Armed Forces,
10/25/2018 FETAL War or Dates
Ir- Place of Death Hospital, Institution
a City, Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
J Manner of Death 0 Natural ❑ Undetermined ❑ Pending
(FETAL) Cause ❑ Accident ❑ Homicide ❑ Suicide 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 ,, Cemetery or Crematory
D Burial 11/01/2018 PINE VIEW CREMATORY •
0 Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
❑ and/or Address
I— Hold
a' Transportation Date Point of
Shipment
co ❑ By Common
❑' Carrier Destination
❑ Date Cemetery Address
Disinterment
Date Cemetery Address
❑ Reinterment f
Permit Issued To ��-r Registration Number
Name of Funeral Home REGAN AND : NNY FUNERAL HOME 01443
Address ,
l' 53 QUAKER RD, QUEENSBURY, N 2804
Name of Funeral Firm Making Disposition orto[Whom
Remains are Shipped, If Other than Above
Address
a
Permission is hereby granted to dispose of the human remains described above as indicated.
10/31/2018
Date ..—% z ,`
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: •
12 Date of Disposition il/( 'it Place of Disposition C4 ' (LawoPraA.
W (address)
2
W
U)
c (section) (lot number) (grave number)
0
S 1
W'; Name of Sexton or Person in Charge of Premises 417kitlfi.4
zi / (please print)
Signature ../'1`P Title / tft'(I
(over)
DOH-1555 (02/2004) •