Halse, Amanda 10/1E1/2018 11:38 15184895632 cBBUTT FREDER1UK rAut Ell
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NEW YORK STATE DEPARTMENT OF HEALTH ,•
Vital Records Seddon Burial - Transit Permit
i_ ,N I V .
tl Name First Middle Last Sex
AMANDA D.`'- .JHALSE FEMALE
1.`1 Date_of Death Age If Veteran of U.S-Armed Forces,
10/06/2018 26 War or Dates
Place of Death Hospital,Institution
. City, or Vitiage Albany or Street Address ALBANY MEDICAL CENTER
Manner of Death Natural Undetermined Pending
❑ Cause ® Accident ❑ Homicide ElSuicide ❑ Circumstances ❑ Investigation
Medical Certifier Name Title
MICHAEL SIKIRICA \ MD
Address
i 112 STATE STREET ALBANY NY 12207
iki.:, Death Certificate Filed District Number Register Number
t City,Town or Village •City of Albany w 101 2213
Date Cemetery or Crematory
0 Burial ' 10/10/2018 PINE VIEW CREMATORIUM
❑Entombment Address
®Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
CI ❑ and/or Address
Hold
f
Qp. •
Transportation Date Point of
Ni ❑ By Common Shipment
S Carrier Destination
❑ Date Cemetery Address
Disinterment
❑ 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
Permission is hereby granted to dispose of the human remains described above as indicated.
10/10/2018 �,.d 9
Date Registrar of Vital Statistics
Issued
m_. (signature)
•` 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: •
Z Date of Disposition /b/It I II Place of Disposition "n� 6,ki4at
w (address)
W
O (section) (lot nu ber) (grave number)
0
Z Name of Sexton or Person in Charge of Premises t n rrr1 t S Q A At
uJ (please print) 1
Signature ./ •40 Title
(over)
• DOH-1555(0212004) • •