Janssen, Ora NEW YORK STATE DEPARTMENT OF HEALTH Z
Vital Records Section - Burial - Transit Permit
A
Name First Middle Last Sex
ORA L. JANSSEN FEMALE
Date of Death Age If Veteran of U.S.Armed Forces,
1/9/12 78 War or Dates NI
Place of Death Hospital, Institution
City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
Manner of Death Natural Undetermined Pending
® ura El Accident El Homicide ❑ Suicide ❑ ❑
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Cause Circumstances Investigation
Medical Certifier Name Title
AUGUSTIN DELAGO MD
Address
43 NEW SCOTLAND AVE ALBANY, NY 12208
Death Certificate Filed District Number Register Number
¢ City,Town or Village City of Albany 101 49
Date Cemetery or Crematory
❑ Burial 1/12/12 PINE VIEW CREMATORIUM
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
4, ❑ and/or Address
1-= Hold
a
Date Point of
d Transportation Shipment
CA ❑ By Common ES Carrier Destination
❑ Disinterment Date Cemetery Address
0 Date Cemetery Address
Reinterment
;E Permit Issued To Registration Number
Name of Funeral Home REGAN & DENNY FUNERAL HOME 01443
' Address
li
53 QUAKER ROAD QUEENSBURY, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
1 Address
-y
Permission is hereby granted to dispose of the human remains cubed above as Indic ed.
Date 1/10/12 Registrar of Vital Statistics`D*' ff , Z
, Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed o ' accordance with this permit on:
Date of Disposition I/3)it- Place of Disposition i‘shcw ( , nc loewr^
a (address)
111
CO
(section) (lot number (grave number)
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WName of Sexton or Person in Charge of Premises a ti r- l«.4'1i-
_
(please print)
Signature //J��/ Title 01 F h1
(over)
DOH-1555(0212004)