Nasierowski, Cathy ! Mk i yOU
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First _ L/ �j iddle Las _ Sex r
zi - 4/ /7. �V 2Si e rows i /
Date of Death Age If Veteran of U.S.Armed Forces, ,(
i 4_
-/, 06 S� War or Dates /
Z Placety, of Death Hor Street
Institutionut f ce.Z1n )Sr-- ��e-r s
2 City,Town or Village City of Albany or Street Address / 7
W Manner of Death r , Natural Undetermined Pendin
W Cause 0 Accident 0 Homicide 0 Suicide ❑ ❑ g
Circumstances Investigation
W Medical Certifier Name Title
G jF 4c_L / i"t",.o4-Ls
Address /
E t 9 S• , . /✓c6`) 7 /( cam
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101
Date Cemetery or Crematory
❑Burial 6 ! / KeViPi..i C::-/- s--Ar y
❑Entombment Address /
®Cremation �,e.ea 4,...7 {t'
Date _ (Place Removed
Z Removal and/or Held
C ❑ and/or Address
Nr Hold ;•ti ;=
0 0. Transportation Date Point of
CO By Common Shipment
p Carrier Destination
❑ Disinterment Date Cemetery Address
❑ Renterment
Date Cemetery Address
Permit Issued To erc r F i���
Nameeof Funeral Home ! Registration Number
cDoe=.5 Z
Address
3?-07 Pia,,,..t. S—r-.) 14_,42... ‘A-)7 / `775r5S------
Name of Funeral Firm Making Disposition or to Whom 1
H; Remains are Shipped, If Other than Above
5 Address
W
d Permission is he by granted to dispose of the uman remains d ed a in ed.
Date 6 �7/ Registrar of Vital Statistics c`Q"
Issued
District Number 101 Place Albany Police Department City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 4.t'304 Place of Disposition (VNv� amiv4orr's
W (address)
2
W
ro
ct
C (section) If (lot number) (grave number)
G
Z Name of Sexton or Person in Charge of Premises ; S telki
W (please print) ��
Signature 4 /t Title ` t,MPtrk
(over)
DOH-1555(02/2004)