Davidson, Mary NEW YORK STATE DEPARTMENT OF HEALTH : • ixi I I ISBurial - Trans(Permit
Vital Records Section
Name First Middle Last Sex
MARY BETH DAVIDSON FEMALE
Date of Death Age If Veteran of U.S.Armed Forces,
05/24/2014 58 War or Dates
H Place of Death Hospital, Institution CAPITAL DISTRICT PSYCHIATRIC
Z City ,Town or Village City of Albany or Street Address CENTER
ILI
p Manner of Death Natural Undetermined Pending
ILI ® Cause ❑ Accident ❑ Homicide ❑ Suicide
❑ Circumstances ❑ Investigation
la Medical Certifier Name Title
CI DR. LAURA DIAMOND M.D.
Address
75 NEW SCOTLAND AVE ALBANY, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 998
Date Cemetery or Crematory
El Burial 5/27/2014 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
Q ❑ and/or Address
F` Hold
CO
Date Point of
CL Transportation Shipment
CO ❑ By Common Destination
CI Carrier
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home WILCOX & REGAN FUNERAL HOME 01821
Address
11 ALGONKIN ST. TICONDEROGA, NY 12883
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2' Address
EX
LU
0- Permission is hereby granted to dispose of the human remains described above as indicated.
Date 05/27/2014 Registrar of Vital Statistics ✓.` -P2.4%s � C- 4_e SM
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:
Date of Disposition lo hi)LI Place of Disposition led LAM .—
w (address)
w
co
r (section) , (lot number) (grave number)
0
C'
Name of Sexton or Person in Charge of Premises irk... _notILI
(please print)
Signature9L 4. voe Title COCillfrat
(over)
DOH-1555 (02/2004)