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NEW YORK STATE DEPARTMENT OF HEALTH . . Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Genesis Joseph Scott St. John Fetal
Date of Death Age If Veteran of U.S.Armed Forces,
12/13/2012 Fetal War or Dates No
I— Place of Death Hospital, Institution
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City ,Town or Village City of Albany or Street Address Albany Medical Center Hospital
0 Manner of Death Natural Undetermined Pending
v qd-a i Li Natural
❑ Accident ❑ Homicide El Suicide ❑ Circumstances ❑ Investigation
W Medical Certifier Name Title
G W. Bruce Clark MD
Address
585 New Loudon Road Latham, NY 12110
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 lei.-
Date Cemetery or Crematory
❑ Burial 12/21/2012 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury NY
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
F- Hold
N
Date Point of
it Transportation Shipment
(/) ❑ By Common p Carrier Destination
❑ Disinterment
Date Cemetery Address
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home Maynard D. Baker 01130
Address
11 Lafayette Street Queensbury, NY
Name of Funeral Firm Making Disposition or to Whom
` Remains are Shipped, If Other than Above
2 Address
W
a-' Permission is hereby granted to dispose of the human remains described,above as inndicated.
Date 12/21/2012 Registrar of Vital Statistics ! Q • l
Issued (signature) y
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:
zDate of Disposition (Z-nv It Place of Disposition .?tit ew Cr rc+drrvN,a
tu (address)
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cc (section) (lot number) (grave number)
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Z Name of Sexton or Person in Charge of Premises P,ite( - watt
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(please print)
Signature Title C e41tlPrt c�JI,
(over)
DOH-1555 (02/2004)