Mattison, Inez NEW YORK STATE DEPARTMENT OF HEALTH f- % ? 333
Vital Records Section Burial - Transit Permit
•
Name First Middle Last Sex
Inez A. Mattison Female
Date of Death Age If Veteran of U.S. Armed Forces,
05 / 01 / 2016 74 War or Dates No
} ' Place of Death Hospital, Institution or
City, Town or Village City of Albany Street Address Albany Medical Center Hospital
a Manner of Death❑ Natural Cause Accident E Homicide Suicide 7 Undetermined —Pending
Circumstances —Investigation
tu Medical Certifier Name Title
0 Darcy L. Miller M.D.
Address
AMCH, 43 New Scotland Ave., Albany, NY 12208
ffii Death Certificate Filed District Number Register, r
City, Town or Village City of Albany 0101 /
iiiiii❑Burial Date Cemetery or Crematory Jrbe
❑Entombment 51 3�/6 O,ve�/o,,� (rc9m2far/vt-,
Address //
Cremation ,.)63eP43ki,ry , A)/
Date Place Removed
9.®Removal 05 / 03 / 2016 and/or Held PINEVIEW CREMATORIUM
and/or Address� •
Hold QUEENSBURY, NY
f.n0 Date Point of
tiElTransportation Shipment
0 by Common Destination
Carrier
:' Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
ilg: Name of Funeral Home MASON FUNERAL HOME 01117
iiiM Address
18 GEORGE ST., FORT ANN, NY 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
. Address
114
'`` Permission is hereby granted to dispose of the human re ains described ve as indicated.
Mi
Date Issued 5/2/2016 Registrar of Vital Statistics fcull ,��-i (\ti C-
nature)
District Number 0101 Place City of Albany , New York
>.. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
141 Date of Disposition SI 3A, Place of Disposition flits Gm4iott
w
2 (address)
111
In
CC (section) _(lot number.), (grave number)
Name of Sexton or Person ip Charge of Premises
(4(
•
Z //?/, please print) •
Ill Signature l Title affniiIX
(over)
DOH-1555 (02/2004)