Kuba, Cameron NEW YORK STATE DEPARTMENT OF HEALTH # 313
Vital Records Section re Burial - Transit Permit
Name First Middle Last Sex
CAMERON MICHAEL KUBA MALE
Date of Death Age If Veteran of U.S.Armed Forces,
05/13/2014 1 War or Dates
F—, Place of Death Hospital, Institution
2 City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
Manner of Death Natural Undetermined Pending
LU ® Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Circumstances ❑ Investigation
aMedical Certifier Name Title
a SEAN DONOVAN MD
Address
43 NEW SCOTLAND AVE., ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 939
Date Cemetery or Crematory
❑ Burial 05/16/2014 PINEVIEW CREMATORIUM
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z ❑ Removal and/or Held
and/or Address
H Hold
Transportation 15
Date Point of
0. Shipment
CO ❑ By Common
0 Carrier Destination
ID Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home BARTON-MCDERMOTT F.H. 00141
Address
9 PINE ST., CHESTERTOWN NY 12817
Name of Funeral Firm Making Disposition or to Whom
rik Remains are Shipped, If Other than Above
Lei Address
0 Permission is hereby granted to dispose of the human remains described above as indicated.
Date 05/16/2014 Registrar of Vital Statistics
Issued (signature)
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 tV(y Place of Disposition 2vaw C,,—„1r.v---
L (address)
tu
it (section) (lot number) (grave number)
o
zName of Sexton or Person in Charge of Premises 711.4,14... Se„ -
(please print)
Signature 4 1._ Title 470,0 in iirat
(over)
DOH-1555 (02/2004)