Olmstead, Shirley 14
NEW YORK STATE DEPARTMENT OF HEALTH Z�
Vital Records Section F 1 Burial - Transit Permit
Name 'First Middle L st Se
v>. e lm�. e a cue . _.. ,.,2 ins
Date of Death Age If Veteran of U.S.Armed Forces,
1 —a—D / a 7(0 War or Dates 1Vi0
WI—Z City
Place, f Deathr gCity orH Streettal, Institution ^r, r �� I �,/ r\ `
'' Cit Town or Village of Albanyor Street Address !Y.t � /J ����
a Manner of Death Natural ❑ Undetermined ❑ Pending
VCause ❑ Accident ❑ Homicide ❑ Suicide Circumstances Investigation
W Medical Certifier Name Title
CI M �
Address
A l ban v A/1-ed 1 (a 1 re nit',A l La n y /1/Y
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101
Date C tery or Cf ematory /
El Entombment El Burial ',q- �o j a %i e, 1'f P-Gc) t jY TO
®Cremation Address
(tee rob r?Lr Li / .i Removed
Date Placee Removed
Z Removal and/or Held
Q ❑ and/or Address
F_ Hold
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O Date Point of
a Transportation Shipment
Cl) 0 By Common
p Carrier Destination
❑ Disinterment
Date Cemetery Address
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home �6 � �e ,.1 / _// / )'t 11)( . 00,--; I/
Address
Name of Funeral Firm Making Disposition or to Whom Y
E.: Remains are Shipped, If Other than Above
g` Address
W
0-; Permission is hereby granted to dispose of the human remains described above as indicated.
Date pt 61( ta` Registrar of Vital Statistics '6'°�'14'
Issued (signature)
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?tea
with this` permit on:
li Date of Disposition 11 (I lit Place of Disposition 1114,... `min t-u 4'04i,`
ILI (address)
w
Cl)
W (section) (lot number) (grave number)
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0
W' Name of Sexton or Person in Charge of Pr mises 71t n S kr- {M,l�-
(please print)
Signature C ..,� Title Cc�i� '1Q0�
(over)
DOH-1555 (02/2004)