Husson, Shelly NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section - Burial - Transit Permit
Name First Middle Last Sex
Shelly L. Husson Female
Date of Death Age , If Veteran of U.S. Armed Forces,
1 1 /1 1 /1 1 48 War or Dates 1 982-1 985
}- Place of Death Hospital, Institution or
City, ToANIAVIAM§tek Albany Street Address 113 Holland Avenue
Manner of Death®Natural Cause 0 Accident Homicide 0 Suicide El Undetermined ri Pending
LLE Circumstances Investigation
ili Medical Certifier Name Title
Q Suchecki
M.D.
Address
113 Holland Avenue
Death Certificate Filed District Number Register Number
City, TelliCXXXIIIDIWK Albany 1 98 1 47
CI Burial Date Cemetery or Cremary
Entombment Addr�191
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Date ii Plate Removed
❑Removal and/or Held
2 and/or Address
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0 Date Point of
%0 Transportation Shipment
O by Common Destination
Carrier
El Disinterment Date Cemetery Address •
El Reinterment Date Cemetery Address
>: Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01 1 99
Address 6357 State Rte 30
EI Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
', Address
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"" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11 /1 1 /1 1 Registrar of Vital Statistics James Arrington, Manager VSC
(signature)
District Number 1 98 Place DVAMC Albany, NY 12208
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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ILI Date of Disposition pot/ rIlli jai Place of Disposition X,ntV 4N.) auliorli,r.)
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1e (section) / . �)(lot number) (grave number)
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• Name of Sexton or Pers in Charge of Premises {� r th�l}
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▪ Signature ILTitle G QeOfleiVtom.
(over)
DOH-1555 (02/2004)