Dickenson, Haley NEW YORK STATE DEPARTMENT OF HEALTH ) i Ilk I
Vital Records Section Burial - Transit Permit
Name First Middle t Last Sex
HALEY JAMES DICKENSON FEMALE
Date of Death Age If Veteran of U.S.Armed Forces,
02/11/2014 3 MTS,11 D War or Dates
I— Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER HOSPITAL
pManner of Death Natural ❑ Undetermined ❑ Pending
W ® Cause ❑ Accident ❑ Homicide ❑ Suicide Circumstances Investigation
W Medical Certifier Name Title
G CAROLYN ROBBINS LEVINE M.D.
Address
43 NEW SCOTLAND AVE ALBANY, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 308
Date Cemetery or Crematory
❑ Burial 02/17/2014 PINE VIEW CREMATORIUM
❑ Entombment Address
H Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
Q ❑ and/or Address
H Hold
U)
O Date Point of
a Transportation Shipment
Cl) ❑ By Common
Destination
p Carrier
❑ Disinterment
Date Cemetery Address
❑ 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 12839
Name of Funeral Firm Making Disposition or to Whom
H
Remains are Shipped, If Other than Above
2 Address
CL
O Permission is hereby granted to dispose of the human remains described above as indicated.
Date 02/14/2014 Registrar of Vital Statistics �"'"�' L � Su
Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in /0 accordance with this permit on:
Z Date of Disposition a��l liW Place of Disposition '1 � C• +'..
W (address)
u.l
co
cr (section) (lot number) (grave number)
0
0
W Name of Sexton or Person in Charge of Premises di$trU-
—Ct..'`r
(please print)
Signaturefk. "L Title C to fit
(over)
DOH-1555 (02/2004)