Rescott, Noah NEW YORK STATE DEPARTMENT OF HEALTH r $��
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
NOAH RESCOTT FETAL
Date of Death Age If Veteran of U.S.Armed Forces,
10/26/2017 FETAL War or Dates
f- Place of Death Hospital, Institution
-Z City ,Town or Vill e City of Albany or Street Address ALBANY MEDICAL CENTER
-W Manner of Dea Natural Undetermined Pending
❑ Accident ❑ Homicide ❑ Suicide ❑ ❑
VCause Circumstances Investigation
t Medical Certifier Name Title
a CAROLYN SLATCH 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
' Burial 10/30/2017 PINEVIEW CREMATORY
Wntombment
Address
remation QUE.ENSBURY NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
H Hold
N
Q Date Point of
O. Transportation Shipment
Cl) ❑ By Common 8 Carrier Destination
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home MB KILMER FH 01079
Address
82 BROADWAY FORT EDWARD NY 12828
' Name of Funeral Firm Making Disposition or to Whom F
Remains are Shipped, If Other than Above
2' Address
CC
Q. Permission is hereby granted to dispose of the human remains descri a agov s mdica
Date 10/27/2017 I
Issued Registrar of Vital Statistics \- ( fo
(signs re)
District Number 101 Place City of Albany, NY (\ J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
li Date of Disposition II /2 1(l Place of Disposition i t&I V'-v0 trom1 j-t%,
w - (address)
w
co
r (section) (lot number) (grave number)
0
CI 41-
Z; Name of Sexton or Person in Charge of Premises /4,,,, 51
w (please print)
Signature 4 Title (P M 114,
(over)
DOH-1555 (02/2004)