Anderson, Baby NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Tran it Permit
Name First Middle Last Sex
Baby Anderson Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 11,2012 Still birth War or Dates N?A
Place of Death Hospital, Institution or
ZCity, Town or Village Albany Street Address Albany Medical Center
p Manner of Death X Natural Cause Accident I (Homicide Suicide Undetermined Pending
W Fetal Circumstances Investigation
w Medical Certifier Name Title
0 Tabitha Kane,MD
Address
AMCH,43 New Scotland Avenue,Albany,NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village City of Albany 0101
❑Burial Date Cemetery or Crematory
❑Entombment Januarylt 2012 Pine View Crematory
Address
X❑Cremation , Queensbury, New York
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
u) I !Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 0028( O43-21
Address
68 Main Street,Hudson Falls, NY 12189
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date issued 01/15/2012 Registrar of Vital Statistics (air (V. 8 byvvafa I .1 40)
(signature)
District Number 0101 Place City of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition I flo/t2 Place of Disposition „p lAcui tar,,,_•
W (address)
co
(section) l/ `` (lot num�) (grave number)
p Name of Sexton or Person in Charge of Premises /hr,st N- JtNHtt
`ZI (please print)
Signature ATitle�
(over)
DOH-1555 (02/2004)