Robinson, Mitzi M Q..........).-
' 4 gG
NEW YORKSTATE DEPARTMENT OF HEALTHBurial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mitzi M Robinson Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/26/2022 86 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
ILI Manner of Death ❑X Natural Cause IllAccident Li Homicide Suicide Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
0 Alon Jacobs-Friedman NP
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 2259
RBurial Date Cemetery,Crematory or Facility Name
09/29/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
O Ei Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
d Date Point of
Cl)❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
a Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/29/2022 Registrar of Vital Statistics 'Daniel S gillespie(Electronically Signed)
(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: /if
Z Date of Disposition 1)30/iL Place of Disposition on, _
W
2 /address/
W
N
(section)CC Z A _ /lot number) cse (grave number)
0 Name of Sexton or Person in Charge of Premises 40t,
�`Q( �
Ilptease print)
W Signature Title U irICM#�
DOH-1555(07/18)p 1 of 2
r
Public Health Law Sec. 4145(2b)
1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#