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Mancini, Karen J. /10 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records • ` • Name First Middle Last Sex Karen J.Mancini Female Date of Death Age If Veteran of U.S.Armed Forces, 10/11/2020 78 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Albany Street Address St Peters Hospital p Manner of Death © Natural Cause Accident Homicide Suicide 1=1 Undetermined ❑Pending W Circumstances Investigation U W Medical Certifier Name Title CI Ji Ma MD Address 315 S Manning Blvd,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 2181 ❑Burial Date Cemetery,Crematory or Facility Name 10/13/2020 Pine View Crematory Entombment Address iCremation Queensbury Town,New York Donation 0 Removal Date Place Removed and/or and/or Held Hold Address 0 a 1-1 Date Point of (A ❑Transportation by Common Shipment Carrier Destination Date Cemetery Address Ei Disinterment Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom N Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/13/2020 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed) (signature) District Number 0101 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /11461- Date of Disposition loMI1110 Place of Disposition s �- ` - 2 (address) W CC (section) / /lot number (grave number) o Name of Sexton or Person in Charge of Pr ises G/1ris ` M� (ple se print) �^ �� IlJ Signature ( Title ! ` 1( DOH-1555(07/18)p id 2 � 1 Public Health Law Sec. 4145(2b) K I Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#