Rinn, Ero NEW YORK STATE DEPARTMENT OF HEALTH - '--1 Burial - Trarsi `�ermit
Vital Records Section
Name First 6.1zo Middle ` Last (Z(lo a^ Sex F
Date of Death Age If Veteran of U.S.Armed Forces,
/N f��V 5- 01 War or Dates --
e of Death Hospital, Institution
i , Town or Village City of Albany or Street Address Pr1; ' AlebC42CC-VC/it-4-
0 anner of Death x Natural ❑ Undetermined ❑ Pending
tit Cause ❑ Accident ❑ Homicide ❑ Suicide
Circumstances Investigation
3't! Medical Certifier Name Title
' Cneiswpt stiy/f-EPEL M b
4 Address
CO N&z) SW 72 44N4 ; f tatt�Y� ,lh, /2 20 0
raiDeath Certificate Filed District Number Register Number
_ Town or Village City of Albany 101
Date Cemetery or Crematory
❑ Burial /z7/ //S''" /0 0C!s,) C 16.40-717RY
Address
TE Cremation f
.11)SZsilhee An.
Date Place Removed
Z Removal and/or Held
52' ❑ and/or Address
IC Hold
(A
LE Transportation Date Point ofShipment
❑ By Common
f Carrier Destination
❑ Date Cemetery Address
Disinterment
Li Reinterment
Cemetery Address
Reinterment
Permit Issued To Registration Number
R
t Name of Funeral Home /WMOR6- /4--�/J L /ORE 0094r g
114 Address
IVA 7 v,i/;.ir4 44,6 r cog/.vm� ,(Jy, /z 22-2.
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby g anted to dispose of the human remains descri d above„win icated.
51
11,
Date �[
, Issued /C J (f l -� Registrar of Vital Statistics ( 7 /`� `
(signature)
,, District Number 101 Place Albany Police Department City of Albany, NY
4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition Io/5/1 C. Place of Disposition - ./AL ( roc .......
It (address)
E.
0`
3 (section) (lot
number)L_ C (grave number)
e` Name of Sexton or Person in Charge of Premises L is-7 iifrl
J (please print)Signature Title ^1
(over)
DOH-1555 (9/98)