Damiani, Rose NEW YORK STATE DEPARTMENT OF HEALTH IF 1ig
Vital Records Section , A Burial - Transit Permit
Name First Middle x Last Sex
Rose Damiani Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/12/2016 . 91 War or Dates No
I— Place of Death Hospital, Institution
Z': City , Town or Village City of Albany or Street Address Albany Medical Center
p Manner of Death Natural ❑ Undetermined ❑ Pending
® ❑ Accident ❑ Homicide ❑ Suicide
W Cause Circumstances Investigation
U; Medical Certifier Name Title
W
C3 Maraj, Anita MD
Address
43 New Scotand Ave. Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 0335
Date Cemetery or Crematory
❑ Burial 02/16/2016 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date , Place Removed
Z Removal and/or Held
0 ❑ and/or Address
I— Hold
C- )'
Q; Date Point of
O^ Transportation Shipment
Cl)' ❑ By Common
CI Carrier Destination
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home W.B. Kilmer Funeral Home 01079
Address
82 Broadway Fort Edward, NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ce
0- Permission is hereby granted to dispose of the human remains describe a or as in4,1 ed.
�G% C Date 02/12/2016 Registrar of Vital Statistics ,, C9�
Issued (sig ature)
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 Z I($ i ra [.er ib Place of Disposition r
w (address)
wt
O (section) (lot number) (grave number)
CI
w Name of Sexton or Person in Charge of Premises t1t4 £ r*i
(please print)
Signature a - Title C5t
(over)
DOH-1555 (02/2004)