Jones, Jenifer NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Na First Middle Last Se
Date De th Age f Veteran of U.S.Armed Forces,
I S (0 I )3 S 1 War or Dates 1,
'= Place of Death Hospital, Institution ; ,, G
Z, City,Town or Village City of Albany or Street Address . y� �-f�i'""l
1 Manner of Death Natural Undetermined �0 Pbndin
0 Accident ❑ Homicideg
W, Cause 0 Suicide 0 Circumstances ❑ Investigation
r Medical Certifier Na Title
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x Death Certificate Filed Di§trrict Number Register Nu
City,Town or Village City of Albany 101 , 3'v"
Date Ce ptery or prematory ri
ElBurial 81 1 I 2.0 13 / /r?P Ili fa) w'1v
❑ Entombment Address 7
Vj Cremation
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Date Pace Removed
Z Removal and/or Held
❑ and/or Address
H Hold
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a' Transportation Date Point of
CO 0 By Common Shipment
5 Carrier Destination
❑ Disinterment
Date Cemetery Address
0 Date Cemetery Address
Reinterment
Permit Issued To Registration Number
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Name of Funeral Home kuty€A4 't..e.A.AC.,t_ ilk .,.I 0 dam//
Address
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Name of Funeral Firm Making Disposition or to W om
Remains are Shipped, If Other than Above
P Address
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0 Permission is her by granted to dispose of the human remains descr ed above a indicated.
s � Date3 7� ��'
ed r /3 Registrar of Vital Statistics A 1'7`-- (,LL ,
(signature)
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District Number 101 Place Albany Police Department City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
HI p � 1
li Date of Disposition (gi'Ii3 Place of Disposition �+r.tth 1- Lip (61011.8.
w (address)
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O (section) (lot num r),_ (grave number)
Q SeirIi
Name of Sexton or Person in Charge of Premises r-
(please print)
Signature /I Title qr n e
(over)
DOH-1555(02/2004)