Fosberry, Cynthia PrNEW YORK STATE DEPARTMENT OF HEALTH # 3 ff
Vital Records Section Burial - Transit Permit
•
Name First Middle Last Sex
Cynthia L. Fosberry Female
Date of Death Age ' If Veteran of U.S.Armed Forces,
04/24/2016 68 War or Dates No
I— Place of Death Hospital, Institution
Z City , Town or Village City of Albany or Street Address Albany Medical Center Hospital
Lii
0; Manner of Death Natural ❑ Undetermined ❑ Pending
W ® Cause ❑ Accident ❑ Homicide ❑ Suicide
Circumstances Investigation
CU Medical Certifier Name Title
Prahlad Gadhavi MD
Address
43 New Scotland Ave. Albany, NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village City of Albany 101 889
Date Cemetery or Crematory
❑ Burial 04/26/2016 Pine View Crematory
❑ Entombment Address
® Cremation
Queensbury, NY
Date Place Removed
Z ❑ Removal and/or Held
and/or Address
H Hold
U
d' Transportation Date Point of
V) El By Common Shipment
0 Carrier Destination
❑ Disinterment
Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church St. Lake Luzerne, NY 12846
FName of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
� Address
W'
C- Permission is hereby granted to dispose of the human remains described naove as iTzlifted.
Date 04/25/2016 Registrar of Vital Statistics L tDoQ� 4 ii
Issued
(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:
Z Date of Disposition t(' /f,is Place of Disposition X 00-/ (041710,.
w (address)
w
co
re (section) (lot number) (grave number)
0
WName of Sexton or Person in Charge of Premises hil Qyri'
(please print) I►
Signature a i�! �i Title arEMIL
(over)
DOH-1555 (02/2004)