Hale, Baby r N
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit P rmit
Vital Records Section
Name First Middle Last Sex
Baby Hale Fetal
Date of Death Age If Veteran of U.S.Armed Forces,
April 6, 2013 Fetal 33 War or Dates
I Place of Death Hospital, Institution
Z City,Town or Vil1ag City of Albany or Street Address Albany Medical Center
Manner of Deat Natural Undetermined Pendin
a � ❑ Accident ❑ Homicide ❑ Suicide El ❑ g
Ill Cause Circumstances Investigation
WMedical Certifie Name Title
Ca Philip Clements MD
Address
43 New Scotland Ave., Albany, NY 12208
Death Certificate Filed District Number Register plumber
City,Town or Village City of Albany 101 p it C .
Date Cemetery or Crematory
❑ Burial April 10, 2013 Pineview
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
Q ❑ and/or Address
F" Hold
U)
Q Date Point of
CL Transportation Shipment
Cl)' ❑ By Common Destination
i i Carrier
❑ Disinterment
Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
.. Remains are Shipped, If Other than Above
Address
CL
W'
G- Permission is hereby granted to dispose of the human remains described abov as i/ndiiccatteed./�
Date April 8, 2013 Registrar of Vital Statistics �� �' l� l� 7—gfmot/
Issued (signatu e) i
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:
li Date of Disposition y-a- _ Place of Disposition 'C,�-aAk$P4Crt".4)(ta-s-
III
(address)
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ce (section) (lot number)c,, (grave number)
0
CI
Name of Sexton or Person in Charge of Premises tip orb
(please print) 1111
Signature 41Title C rlv4
(over)
DOH-1555 (02/2004)