Clock, Elisabeth NEW YORK STATE DEPARTMENT OF HEATH •� ,'�
Vital Records Section Burial - Transit ermit
Name First Middle Last Sex
Elisabeth A. Clock Female
Date of Death Age If Veteran of U.S.Armed Forces,
March 5, 2013 60 War or Dates No
I- Place of Death Hospital, Institution
WCity,Town or Village City of Albany or Street Address Albany Medical Center
Manner of Death Natural Undetermined Pendin
® ❑ Accident ❑ Homicide ❑ Suicide ❑ ❑ g
III Cause Circumstances Investigation
✓ Medical Certifier Name Title
CI Farhana Chaudhary MD
Address
43 New Scotland Ave., Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 470
Date Cemetery or Crematory
❑ Burial March 6, 2013 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
H Hold
Cl)
O Date Point of
i1 Transportation Shipment
CO ❑ By Common
Carrier Destination
❑ Date Cemetery Address
Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home Huestis Funeral Home, Inc. 00824
Address
25 Maple Street, Eillsboro, NY 12996
F' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
0- Permission is hereby granted to dispose z::r::t::::i:scr;::: sdI
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March 5, 2013 ` � °
a ure) , 1
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 3-1-0 Place of Disposition '6�da� +!✓ C ;hrrfi�
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re (section) 4 (lot number) (grave number)
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Name of Sexton or Person in Charge of Premises
(please print)
Signature 410.— Title CV/MA-TN,
(over)
DOH-1555 (02/2004)