Dickson, Cindy / )
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Cindy L. Dickson Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/20/2016 46 War or Dates No
F- Place of Death Hospital, Institution
W City,Town or Village City of Albany or Street Address Albany Medical Center
• Manner of Death Natural Undetermined Pendin
® IIIAccident ❑ Homicide ❑ Suicide ❑ ❑ g
✓ Cause Circumstances Investigation
° Medical Certifier Name Title
p John Dalfino MD
Address
43 New Scotland Ave. Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 0158
Date Cemetery or Crematory
❑ Burial 1/26/2016 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
P. Hold
N
Q Date Point of
a Transportation Shipment
(/), ❑ By Common
a Carrier Destination
❑ Date Cemetery Address
Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave. Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
Address
W,
G. Permission is hereby granted to dispose of the human remains describ de as iidicat .
Date 01/21/2016 Registrar of Vital Statistics �'t �`
Issued ( gnature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance yvith/this permit on:
Z Date of Disposition I�21)IL Place of Disposition ..gL'�..� Ctr�r„..
w (address)
w
IX (section) (lot number) (grave number)
O
0
Z Name of Sexton or Person in Charge of Premises 4c\
hey. JDHM4
w (please print)
�74 Signature l/' Title W 1.
(over)
DOH-1555 (02/2004)