Robinson, Dezalia (Q
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
DEZALIA / FAttl-&)O ) eeTek4 F
Date of Death Age If Veteran of U.S.Armed Forces,
4• /19/12 FETAL War or Dates
:1 Place of Death Hospital, Institution
.Z1 City,Town or Village City of Albany or Street Address
ift
Ma �-r of Death Natural ❑ Undetermined ❑ Pending
A� ❑ Cause 0 Accident ❑ Homicide ❑ Suicide Circumstances Investigation
g .ical Certifier Name Title
BRUCE CLARK MD
Address
43 NEW SCOTLAND AVENUE ALBANY, NY 12208
Death Certificate Filed District Number Register Number
t- `' City,Town or Village City of Albany 101 FETAL
❑ Burial Date Cemetery or Crematory
❑ Entombment 4/26/12 PINEVIEW CEMETERY CaEhw4Tu(k`7
®Cremation Address 11
QUEENSBURY, NY 14 $Uy
Z Date r Place Removed
❑ Removal and/or Held
and/or Address
Hold
CO
a Transportation Date Point of
Shipment
t/) ❑ By Common Destination
G Carrier
El Disinterment
Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
i Name of Funeral Home EDWARD L. KELLY FUNERAL HOME 00519
_: A• ddress
' SCROON LAKE,NY J a 10
Name of Funeral Firm Making Disposition or to Whom
$.14`' Remains are Shipped, If Other than Above
re Address
if
.; P• ermission is hereby granted to dispose of the human remains ribed above as Indic ted.
Date 4/25/12 Registrar of Vital Statistics r
Issued �^'a'` ,cfp:(signature)
District Number 101 Place City of Albany, NY [ 0(
I certify that the remains of the decedent identified above were disposed of in accordanceP114
with this permit on:
Z Date of Disposition gill lit Place of Disposition V t( CIONrriors
W (address)
2
W
N
o (section) (lot number) (grave number)
p Z Name of Sexton or Person in Charge of Premises 44-ce4r- St+Nfi-
W
/� � J (please print)
G
Signature /{ `- Title CQ E M PrrOlt
(over)
DOH-1555(02/2004)