Lindsell, Baby I
NEW YORK STATE DEPARTMENT OF HEALTH Burial - TraJit"i5ermit
Vital Records Section
Name First Middle Last Sex
BABY LINDSELL FETAL
a.
Date of Death Age If Veteran of U.S.Armed Forces,
05/01/2013 FETAL War or Dates
,= Place of Death Hospital, Institution
City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
Manner of Deat ❑ Natural ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Cause Circumstances Investigation
Medical Certifier Name Title
PHILIP CLEMENTS MD
Address
40 43 NEW SCOTLAND AVE., ALBANY NY 12208
;. Death Certificate Filed District Number Register Number
irji City,Town or Village City of Albany 101 FETAL
Date Cemetery or Crematory
❑ Burial 05/06/2013 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
Q 0 and/or Address
F Hold
VI
O Date Point of
D. Transportation Shipment
(I)' ❑ By Common Destination
p Carrier
El Disinterment Date Cemetery Address
-
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. KILMER F.H. 01078
3
Address
iiii 136 MAIN ST., SOUTH GLENS FALLS, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains des 'ibed above as indi a d. l.k
. k -S .
Date 05/03/2013
4 Registrar of Vital Statistics
Issued (signature)
District Number 101 Place City of Albany, NY
a
I certify that the remains of the decedent identified above were disposed of in accord ce with this64
ermit on:
Date of Disposition 6'4-t. Place of Disposition I "' ifif`'
111 (address)
tu
co
ce (section) /® (lot number) (grave number)
Z 4
Name of Sexton or Person in Charge of Pre 'ses n) t"
(please print)
Signature Title 111 Wt
(over)
DOH-1555 (02/2004)