Butters, Baby A 3—)14
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
BABY BUTTERS FETAL
Date of Death Age If Veteran of U.S.Armed Forces,
04/22/2021 FETAL War or Dates
Place of Death Hospital, Institution
City,Town-owe ALBANY or Street Address ALBANY MEDICAL CENTER
Manner of Death 0 Natural Undetermined Pending
(FETAL) Cause ❑ Accident ❑ Homicide El Suicide ❑ Circumstances ❑ Investigation
Medical Certifier Name Title
CORRINE MCLEOD MD
, Address
43 NEW SCOTLAND AVE, ALBANY NY 12208
: Death Certificate Filed District Number Register Number
I} s City,Town-or-Village ALBANY, NY 0101 FETAL
Date Cemetery or Crematory
❑ Burial 04/27/2021 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Removal and/or Held
,II' ❑ and/or I Address
Hold
Q Date Point of
O. Transportation Shipment
V7 ❑ By Common Destination
p Carrier
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Renterment
A Permit Issued To Registration Number
4 Name of Funeral Home SINGLETON SULLIVAN POTTER FUNERAL HOME 01596
Address
407 BAY RD, QUEENSBURY, NY 12804
Name of Funeral Firm Making Disposition or to Whom
4)2 Remains are Shipped, If Other than Above
Address
' Permission is hereby granted to dispose of the human remains described above as indicated.
04/27/2021 x-ar,- 1 -
Date Registrar of Vital Statistics
Issued
(signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance ' ' permit
z Date of Disposition_ ASIZ$,14 Place of Disposition (address)
2
W
W (section) (lot nu er) (grave number)
0
W Name of Sexton or Person in Charge of Premises r��IV < v lT
(p se print)
Signature ��' Title irk
(over)
DOH-1555(02/2004)
Public Health Law Sec. 4145(2b) 01 4 7 4 6
Receipt
Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#