Cook, Fetal pwrik
NEW YORK STATE DEPARTMENT OF HEALTH Burial - TraitWrmlt
Vital Records Section
Name First Middle Last Sex
FETAL COOK FETAL
Date of Death Age If Veteran of U.S.Armed Forces,
4/5/16 FETAL War or Dates NO
I— Place of Death Hospital, Institution
Z City , Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
U Manner of Death Natural ❑ Undetermined ❑ Pending
ire-0., L ❑ Cause ❑ Accident ❑ Homicide ❑ Suicide Circumstances Investigation
o Medical Certifier Name Title
113
(3 W. BRUCE CLARK MD
Address
43 NEW SCOTLAND AVE ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 FETAL
Date Cemetery or Crematory
❑ Burial 4/7/2016 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
Q ❑ and/or Address
F- Hold
V-)
Q Date Point of
IL Transportation Shipment
to ❑ By Common Destination
Carrier
❑ Date Cemetery Address
Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home CARLETONS FH HUDSON FALLS NY 00281
Address
68 MAIN ST PO BOX 67 12839
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
• Address
Ill
IZ Permission is hereby granted to dispose of the human remains described bove as i ted.
��t
Date 4/6/2016 /; Cia 6 in� oCkle0 I Ct
Issued Registrar of Vital Statistics (sign ture)
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 'until` Place of Disposition _ C4-1 a4W.clora-..
(address)
w,
co
ce (section) (lot number) (grave number)
0
0
w Name of Sexton or Person in Charge of Premises � '�. �l �^"
�'j� (please print) c��
Signature _/ Title l ne
(over)
DOH-1555 (02/2004)