Jenks, Randall NEW YORK STATE DEPARTMENT OF HEALTH # AO
Vital Records Section t .1 Burial - Transit Permit
Name First Middle Last Sex
RANDALL JAMES JENKS MALE
Date of Death Age If Veteran of U.S.Armed Forces,
06/02/2014 42 War or Dates
E Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER HOSPITAL
W Manner of Death Natural Undetermined Pending
® ❑ Accident ❑ Homicide ❑ Suicide ❑ ❑
W` Cause Circumstances Investigation
W Medical Certifier Name Title
Ct MEREDITH CHAN M.D.
Address
43 NEW SCOTLAND AVE. ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1062
Date Cemetery or Crematory
❑ Burial 06/05/2014 PINE VIEW CREMATORIUM
❑ Entombment Address
® Cremation QUAKER RD. QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
F' Hold
to
Date Point of
a Transportation Shipment
U) ❑ By Common p Carrier Destination
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home CARLETON FUNERAL HOME, INC. 00281
Address
68 MAIN ST. P.O. BOX 67 HUDSON FALLS, NY
i` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Ce Address
ILI
CL Permission is hereby granted to dispose of the human remains described above as indicated. /fr/J�
Date 06/05/2014 Registrar of Vital Statistics l
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:
p�
Z Date of Disposition (PAIN Place of Disposition ftvatti e� t"() ,
w (address)
2
LU
co
it (section) (lot num er) (grave number)
O
0 �n�}�,,� wi'1AA
Z Name of Sexton or Person in Charge of Premises tit
w (please print)
Signature Title CaC vL
(over)
DOH-1555 (02/2004)