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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
SHIRLEY NASH FEMALE
Date of Death Age If Veteran of U.S.Armed Forces,
02/09/2017 73 War or Dates NO
I- Place of Death Hospital, Institution
2 City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
go Manner of Death Natural Undetermined Pending
® ❑ Accident ❑ Homicide ❑ Suicide ❑ ❑
W Cause Circumstances Investigation
WMedical Certifier Name Title
CI BARBARA HELENDEL MD
Address
43 NEW SCOTLAND AVE ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 339
Date Cemetery or Crematory
❑ Burial 02/13/2017 PINE VIEW CREMATORY❑ _Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
I Hold
U)
Date Point of
d Transportation Shipment
CO ❑ By Common Destination
Carrier
El Disinterment Date Cemetery Address
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home SINGLETON SULLIVAN POTTER FUNERAL HOME 01596
Address
407 BAY RD QUEENSBURY NY 12804
Name of Funeral Firm Making Disposition or to Whom
N Remains are Shipped, If Other than Above
if Address
W.
IX-, Permission is hereby granted to dispose of the human remains describ-• -i.ove as�indicated. ��/� (�
Date 2/10/2017 Registrar of Vital Statistics
Issued (si. .tu =
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:
ii Date of Disposition 2//s/ /7 Place of Disposition )�7i .t Pet.) Gp�.n4 �zi.��J
L / (address) /
LU
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W (section) (lot number) (grave number)
O'
Z Name of Sexton or P rson in Charge of Premises 1 i .-r 64✓�,c e
w (please print)
Signature Title L re-"4 4;11 01/7-to-'4lJ./
(over)
DOH-1555 (02/2004)