Walters, Jean ik
NEW YORK STATE DEPARTMENT OF HEALTH ` Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Jean M. Walters Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/27/2014 68 War or Dates No
i` Place of Death Hospital, Institution
Ill• City, Town or Village City of Albany or Street Address Albany Medical Center
O Manner of Death ® Natural ❑ Undetermined ❑ Pending
❑ Accident ❑ Homicide ❑ Suicide
W' Cause Circumstances Investigation
V Medical Certifier Name Title
in George Suryal MD
Address
43 New Scotland Ave. Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1826
Date Cemetery or Crematory
❑ Burial 10/02/2014 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
— ❑ and/or Address
Hold
CO
Q Date Point of
p. Transportation Shipment
co ❑ By Common Destination
Ci Carrier
❑ Date Cemetery Address
Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home Brewer Funeral Home Inc. 00211
=:' Address
24 Church St. Lake Luzernem NY 12846
NName of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IL
I_
Permission is hereby granted to dispose of the human remains de • bove as indicated
Date 09/30/2014 r.
Registrar of Vital Statistic
Issued ignature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordancer with this permit on:
li Date of Disposition IOi'21/N' Place of Disposition dU..., I r is.....,
w (address)
w
0?
r (section) i1 (lot number (grave number)
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WName of Sexton or Person in Charge of Premises ' r'f} k`t k
(please print)
Signature 4f ... Title (17A-WW
(over)
DOH-1555 (02/2004)