Fetal 06/24/2022 14:05 15184895632 BBUTT FREDERICK
PAGE 01
NEW YORK STATE DEPARTMENT OF HEALTHCO . # S/3
Vital Records Section Burial - Transit Permit
AEI?! Name First
Middle Last Sex
FETAL FETAL FETAL
" Date of Death • Age If Veteran of U.S.Armed Forces,
O6/21/2022 FETAL War or Dates
Place of Death W Hospital,Institution
Ci .Tewn-er-Village ALBANY or Street Address ALBANY MEDICAL CENTER
T. Manner of Death Natural
(FETAL) ❑ Cause CI Accident 0 Homicide 0 Suicide ❑ Uri enTM ❑ Pending
Medical Certifier Name _ Circumstances Investigation
Tide
. . _ W. BRUCE CLARK MD
11
Address _
43 NEW SCOTLAND AVE, ALBANY NY 12208
Death Certificate Filed
;w City, 1 District Number Register Number
ALBANY, NY 0101 I FETAL
Date Cemeteor Crematory
❑Burial 06/25/2022 PINEW CREMATORY
❑Entombment Address
0 Cremation
QUEENSBURY, NY
Date Place Removed — --
0 Removal and/or Held
P Holdand/or Address
"""'
Date I Point of a ❑
Transportation l
_ By Common Shipment
Q Carrier Destination
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued To Registration Number
s. Name of Funeral Home
REGAN, DENNY, STAFFORD FUNERAL HOME 01443
Address
53 QUAKER RD, QUEENSBURY, NY 12804
Name of Funeral Firm Making Disposition or to Whom ""
• • Remains we Shipped,If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as Indicated_
Date 06/24/2022 ,.x
• . Issued Registrar of Vital Statistics
!'' - (signature)
District Number 101 Place City of Albany, NY
1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on;
Date of Disposition ‘PI?R I Zl Place of Disposition -PnAL/,-., 4---
sit
(address)
S (section) i (lot number) (grave number)
I Name of Sexton or Person in Charge of Premises N, k. f
,( Pnnt)
Signature _ /.../.9 Title [kilo-rig
p"L
(over)
DOH-1555(02/2004)
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#