Vanderklish, Kate NEW YORK STATE DEPARTMENT OF HEALTH 1- - ' b Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
KATE RUTH VANDERKLISH FEMALE
Date of Death Age If Veteran of U.S.Armed Forces,
2/27/11 4HRS15MI War or Dates NO
Place of Death Hospital, Institution
City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
Manner of Death Natural ❑ Undetermined ❑ Pending
® Cause ❑ Accident ❑ Homicide ❑ Suicide
Circumstances Investigation
Medical Certifier Name Title
MYLES BYRD MD
Address
43 NEW SCOTLAND AVENUE ALBANY, NY
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 392
❑ Burial Date Cemetery or Crematory
0 Buombment 3/4/11 PINE VIEW CREMATORY
® Cremation Address
QUEENSBURY, NY
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
f
Transportation Date Point
Shipment
Cl). ❑ By Common Destination
Carrier
Ell Disinterment
Date Cemetery Address
} ❑ Reinterment Date Cemetery Address
,:
Permit Issued To Registration Number
Name of Funeral Home SINGLETON-HEALY FUNERAL HOME 01522
Address
407 BAY ROAD QUEENSBURY, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remai escribed above as indica eDate
Issued 3/2/11 Registrar of Vital Statistics ���' Q
(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:
Date of Disposition Place of Disposition
(address)
itt
C (section) (lot number) (grave number)
a
`A Name of Sexton or Person in Charge of Premises
g (please print)
Signature — Title
(over)
DOH-1555(02/2004)