Conine, Timothy NEW YORK STATE DEPARTMENT OF HEALTH a 1L
Vital Records Section 1 Burial - Transit Permit
Name First Middle Last Sex
in Timothy Michael Conine M
Date of Death Age' If Veteran of U.S. Armed Forces,
ini
July 18, 2014 22 War or Dates
iE"_ Place of Death Hospital, Institution or
'Z City, Town or Village City of Albany Street Address Albany Medical Center
11 Manner of Death ❑Natural Cause Accident Homicide ❑Suicide ❑ Undetermined n Pending
i:wCircumstances Investigation
Medical Certifier Name Title
N. Balasubramaniam M.D.
Address
47 New Scotland Ave. Albany, NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village City of Albany 101
Date Cemetery or Crematory
❑Burial July 21, 2014 Pine View Crematory
Address
✓Cremation Queensbury, NY
Date Place Removed
2 — Removal and/or Held
d —and/or Address
=' Hold
>
O Date Point of
N ❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iii:iii:i: Permit Issued to Registration Number /
ffi3 Name of Funeral Home Regan Denny Stafford Funeral Home
01443
:i Address
53 Quaker Rd. Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
w' Remains are Shipped, If Other than Above
Address
te
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t
i Permission is hereby granted to dispose of the human remains de rib d a ,ove as indicated
glii
'< Date Issued 7/20/2014 Registrar of Vital Statistics s ��_���2 6�
signature)
'3 District Number 101 Place Albany Pol ice Department Albany . NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- �
• Date of Disposition 7-LFI ( Place of Disposition i zv..-d C- qr i'--
(address)
LU
N
cc (section) ynumber) ( (grave number)
GName of Sexton or Person in Ch rge of Premises ,`}y�, �tn�ti,
T (please print) J
W Signature > Title 14
(over)
DOH-1555 (9/98)