Mancusco, Amiya NEW YORK STATE DEPARTMENT OF HEALTH . r
Vital Records Section Burial - Transit Permi tt
NName First Middle Last Sex
AMIYA ROSALEIGH MANCUSO FETAL
Date of Death Age If Veteran of U.S.Armed Forces,
clft 03/18/2014 FETAL War or Dates
Place of Death Hospital, Institution
: City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
Manner of Death'``❑ Natural ❑ Accident ❑ Homicide El Suicide 1-1
Undetermined ri❑ Pending
_l" 1y � Cause Circumstances Investigation
F- Medical Certifier Name Title
DR. KANAAN MD
P. Address
fat 43 NEW SCOTLAND AVE., ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 FETAL
t
Date Cemetery or Crematory
0 Burial 03/21/2014 PINE VIEW CREMATORY
0 Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
❑ and/or Address
Hold
CO
Date Point of
a' Transportation Shipment
CO ❑ By Common Destination
Carrier
El Disinterment
Date Cemetery Address
❑ Date Cemetery Address
Reinterment
-- Permit Issued To Registration Number
Name of Funeral Home COMPASSIONATE FUNERAL CEARE 00364
�� Address
402 MAPLE AVE SARATOGA SPRINGS NY 12866
y N• ame of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ermission is hereby granted to dispose of the human remains described above as indic td. i _
Date 03/21/2014 V ,�^ � .• ((,f I��. t, •
Registrar of Vital Statistics 2 j(1 _ s(
tv, Issued (signature d.
D• istrict 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:
D• ate of Disposition Place of Disposition
W (address)
tu
U)
IX (section) (lot number) (grave number)
0
Z Name of Sexton or Person in Charge of Premises
1' (please print)
Signature Title
(over)
DOH-1555 (02/2004)