Fonda, Jacqueline Ann (2) NEW YORK STATE DEPARTMENT OF H EALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last
Jacqueline Ann Fonda Sex
'•„ I Female
Date of Death I Age I If Veteran of U.S.Annex ces,
07/08/2022 78 Years Waror Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Albany I Street Address Albany Medical Center Hospital
\ Mannerof Death Ei Natural Cause DAccident Homicide ❑Suicide ❑Undetermined ❑Pending
W -
Circumstances Investigation
G Medical Certifier Name Title
Gabrielle Rieth MD
Address
43 New Scotland Ave,Albany,New Vatic 12208
Death Certificate Filed City of Albany District Number Register Number
Cit ,Town or Village 0101 1599
IIBurial Date Cemetery,Crematory or Facility Name
07/13/2022 Pine View Crematory
In Entombment Address
Cremation Queensbury Town,New York
■Donation
0Z■Removal Date Place Removed
F and/or and/or Held
N Hold Address
CO■ ransportation Date Point of
0 by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
I.Re interment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New Yost 12885
Name of Funeral Firm Making Disposition or to Whom
—. Remains are Shipped,If Other than Above
N Address
CC
IL
4 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/12/2022 Registrar of Vital Statistics +Damv/sgr/rpie(E1 rtromuaQysrgned}
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Datc of Disposition 1114 12Z, Place of Disposition V,,,..
4,-
(address)
, (section) (lot number) (gra 1e number)
• Nam!oS Sexton or Person in Charge of P emises rw Sf�- '"`
(plee print)
Title CP/1014 /
S+Snat°re
DOH-1555(07118)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
{
Human remains of ,' 1 , delivered on , 20 '.
/� '
f / f
Pine View Cemetery Representing theftineral home named on burial permit
Official Funeral Directors Reg. or License# - =' "