Kuba, Cara 4112
NEW YORK STATE DEPARTMENT OF HEALTH . .
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cara S Kuba Fetal
Date of Death Age If Veteran of U.S.Armed Forces,
12/30/2014 Fetal War or Dates No
—. Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address Albany Medical Center
la
0 Manner of Death Natural Undetermined Pending
❑ ❑ Accident ❑ Homicide ❑ Suicide ❑ ❑
W Few( Cause Circumstances Investigation
U Medical Certifier Name Title
O W. Bruce Clark MD
Address
43 New Scotland Avenue, Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 Fetal
Date Cemetery or Crematory
0 Burial 01/05/2015 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date °lace Removed
Z Removal and/or Held
O ❑ and/or Address
Hold
U)
Q Date Point of
a Transportation Shipment
Cl) ❑ By Common
0 Carrier Destination
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home Barton McDermott Funeral Home 00141
Address
9 Pine Street, Chestertown, NY 12817
H
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2, Address
W
Q- Permission is hereby granted to dispose of the human remains described above as indicated. l
Date 01/05/2015 Registrar of Vital Statistics Q C*,- kradji c/ , .�ICV V.
Issued (sign ure)
District 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:
Z Date of Disposition (/7/i C. Place of Disposition Cr(/ —
w (address)
w
Ce (section) (lot number) (grave number)
0
W Name of Sexton or Person in Charge of Premises
:gwiric, Sow -
(please print)
1.,"
Signature :"-_, Title MC v1►9fA
(over)
DOH-1555 (02/2004)