Deloriea, Janice 35/
NEW YORK STATE DEPARTMENT OF HEALTH ` '* Burial - Transit Permit
Vital Records Section
Name First _Middle L st Sex
�....
Date of Death �� Age If Veteran of U.S.Armed Forces,
5/ t/ 0) S 73 War or Dates
F- Place of Death Hospital, Institution
City,Town or Village City of Albany or Street Address
Manner of Death Natural Undetermined Pending
tli E Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Circumstances ❑ Investigation
• Medical Certifier Name Title
L , - Ca c•v eA�e.-k. ill /)
Address
' Death Certificate Filed District Nir ber I Register Number
City,Town or Village City of Albany 101
Date
El Burial
or Crematory _ /'
Burial C1///, of Ste. , �V ,.5 C_!`e>" •
Address /
Ef Cremation /
�1..LL en S6 LA/ / ' ) ,t P'
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
1 Hold
CO
0 Date Point of
0. Transportation Shipment
to ❑ By Common
d Carrier Destination
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To ,,— Registration Number
• Name of Funeral Home 'r- / 0 oa 9-?-8/
A• ddress / - r
ee"ti.µ-r- Aye e , G- ��r - . A) i a� v),—,
1 , Name of Funeral Firm Making Disposition or to Whom
R• emains are Shipped, If Other than Above
Address
0 Permission is hereby granted to dispose of the human remains des rib d ab ve as indicated.
• Dssued � 3/+ /f �
�lC �7
y
44 I Registrar of Vital Statistics /' ����
(signature)
District Number 101 Place Albany Police Department 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 to I Ill C Place of Disposition "�'►be
ua (address)
W09
' (section) (lot number) (grave number)
Ca
W Name of Sexton or Person in Charge of Premises r��s
(please print)
6.Signature Title /IX rr ip&
(over)
DOH-1555(9/98)